ED Coding and Reimbursement Alert

Test your knowledge with this real-life scenario

Think you know when to report a level-two emergency department (ED) visit instead of a level-three? See if you can report the correct evaluation and management (E/M) code (99281-99285) for this patient. The ED physician's notes say the following:

Presenting complaint: Patient "thinks she has the flu."

History of present illness: 45-year-old male, generally healthy, has been sick for three days with fever, chills, cough, headache, and body aches. T to 103. Cough nonproductive. No GI symptoms. Two other family members with similar symptoms. Nonsmoker.

Physical exam: T 102 other VS OK. HEENT (-) Neck supple; Chest clear; Heart and Abdomen (-).

ED course: Patient examined. Given ibuprofen, 400 mg. Does not appear to have pneumonia or a CNS infection. I think this is influenza. Too late for specific antivirals.

Disposition: Home rest and fluids. Tylenol or ibuprofen. Recheck for persistent or worsening symptoms.

Diagnosis: Influenza. Should you describe this scenario with 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity) or 99283 (... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity)?

Solution: The most appropriate code for this case is 99283. Most often, in cases like this that may require a level-two or a level-three, the deciding factor is medical decision-making (MDM) - not history and physical - says Robert LaFleur, MD, FACEP, president of Medical Management Specialists in Grand Rapids, Mich.

"Since there are no tests done and no data to review, you're left looking at 'presenting problem' and 'management options' in the risk category, and then at 'number of diagnoses or treatment options' in the remainder of the MDM grid," LaFleur says.

Even if you assume that the management options in this case entailed no more than low-risk factors, the patient still has an acute illness with systemic symptoms. "That is moderate risk in that area, and according to the Table of Risk in the Documentation Guidelines, would make the overall risk also moderate," he says. The documentation guideline rule for the table of risk is that the highest level of risk in any one category (presenting problem[s], diagnostic procedure[s], or management options) determines overall risk.

Reason: The guidelines for selecting the level of MDM state that the physician's documentation must meet or exceed the requirements to satisfy two of these three elements of MDM to [...]