ED Coding and Reimbursement Alert
Consider Added MDM for Young Patients
Question: A 9-month-old child with eyes swollen shut presents to the emergency department. The physician performed a complete review of systems (ROS), four elements of a history of present illness (HPI), and more than 10 elements for the physical exam. However, no lab work was done. The child was given Atarax orally and was sent home with a prescription for Atarax. The diagnosis is allergic reaction, unknown. Which E/M level is appropriate? Iowa Subscriber Answer: Assuming the physician recorded some past family social history (PFSH), the medical decision-making (MDM) component of the E/M service will be the turning point in your selection of level in this situation. Considering only the physician's treatment of the patient, this service appears to involve moderate MDM, which would leave you to choose between a level-three (99283, ED visit for the E/M of a patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity) and a level-four (99284, ... a detailed history, a detailed examination, and medical decision-making of moderate complexity). Level four may be more appropriate in this case because this patient is young. Make sure when you are determining MDM level that you have the proper documentation for the complexity you select, including these three criteria:
ED Coding and Reimbursement Alert
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