Wiki E&M "complexity" level for DX's related to "contact to"/"exposure to" DX's

[kdbeale]

I have a question about E&M level selection. I have a provider billing lots of claims with a DX like acute bronchitis with no documented complications and then codes the exposure to Covid DX Z20.822. The acute uncomplicated code falls into “low” but what about the possible exposure? It seems like the 2 together still fall into low for the DX criteria because the “moderate” descriptions don’t seem to fit. And would a negative or positive Covid test have any bearing on E&M level?

Update: Here's some clarification related to my ask, these claims are Urgent Care claims billing standard E&M codes, and the struggle is mostly with helping the providers understand the E&M leveling and that 2 of the 3 criteria must be met. I was focusing on the piece they were having a hard with which is the diagnoses/problems addressed versus the other 2 pieces of criteria (amount/complexity of data reviewed and patient management). The providers were not understanding that 2 of the 3 criteria had to be met so I was trying to help them understand where the DX's fell on their own accord in the "straightforward, low, moderate, high" criteria specifically.

 

[amyjph]

You would need to look at the whole story/picture, not just that one piece. For example, there could be instances where someone with positive Covid has no symptoms and no treatment required. On the other hand, there could be a patient that is so sick they need to be admitted to the hospital. It's encounter and patient/documentation based, not just the fact that Covid may or may not be present.
In your example, a patient may have bronchitis and possibly had "exposure to Covid", but if they test negative it's just bronchitis. What does the documentation and story say? You have to look at the data and risk too. Or, if not, did the provider want to do it by time? Did they just slap a diagnosis code on the claim but there is nothing to support it in the note? Did they specifically document that someone in the household has positive Covid? Look at it that way.

As an auditor I have reviewed thousands of charts, what I see a lot of times is a coder or provider has the word Covid in the note and someone automatically levels it a 5 without looking at anything else. Usually these end up being level 3 or 4 depending on the note.

 

[kdbeale]

You would need to look at the whole story/picture, not just that one piece. For example, there could be instances where someone with positive Covid has no symptoms and no treatment required. On the other hand, there could be a patient that is so sick they need to be admitted to the hospital. It's encounter and patient/documentation based, not just the fact that Covid may or may not be present.
In your example, a patient may have bronchitis and possibly had "exposure to Covid", but if they test negative it's just bronchitis. What does the documentation and story say? You have to look at the data and risk too. Or, if not, did the provider want to do it by time? Did they just slap a diagnosis code on the claim but there is nothing to support it in the note? Did they specifically document that someone in the household has positive Covid? Look at it that way.

As an auditor I have reviewed thousands of charts, what I see a lot of times is a coder or provider has the word Covid in the note and someone automatically levels it a 5 without looking at anything else. Usually these end up being level 3 or 4 depending on the note.

Agreed. Thank you so much for your reply. It is very difficult when you try to explain these nuances to a provider and they don't seem to grasp that it's more than just their gut feeling that an E&M level should be higher based on differential DX's that cold have been versus the actual outcome and actual documented efforts/risks. Thanks again, truly appreciated!

 

[amyjph]

It can be a little different too depending on the site of service. If you are talking ED vs. office for example.

 

[kdbeale]

It can be a little different too depending on the site of service. If you are talking ED vs. office for example.

Here's some clarification related to my ask, these claims are Urgent Care claims billing standard E&M codes, and the struggle is mostly with helping the providers understand the E&M leveling and that 2 of the 3 criteria must be met. I was focusing on the piece they were having a hard with which is the diagnoses/problems addressed versus the other 2 pieces of criteria (amount/complexity of data reviewed and patient management). The providers were not understanding that 2 of the 3 criteria had to be met so I was trying to help them understand where the DX's fell on their own accord in the "straightforward, low, moderate, high" criteria specifically.
I'll see if I can get them to come around. Thanks again for chiming in, it's always nice to have some support

 

[podcoder70]

The condition itself does not determine low/moderate/high risk. As you stated, 2 of the 3 elements are required, but risk is based on a number of factors based on medical decision making, not just the diagnosis. In fact, a relatively "low risk" diagnosis, such as tinea pedis, can lead to a moderate level e/m if prescription management is performed. The prescription management is a part of the medical decision making in the moderate level. Thus you would have, perhaps, 1 undiagnosed new problem and prescription management and this is a level 4. I recommend that your providers look at the AMA guidelines and use the table in the attached document, pages 8-13.