ED Coding and Reimbursement Alert

Question: Which level 99282 or 99283 would I code an ED visit for a child who presented with a URI (upper respiratory infection) and fever (fever measurement in ED not documented)? An exam was done, no tests were done, and no prescriptions given. Are the final diagnoses URI and fever? I believe the medical decision-making does not warrant a level three, but I have heard that two diagnoses increase the level.

Camille Villanueva
Cape Coral, Fla.

Answer: The diagnoses do not affect the level of service. The issue in this case is the level of medical decision-making because the history and exam are the same for a level two or level three. The data are clearly straightforward, and the diagnostic and management options are moderate.

Risk is the final determinant of the level of the service. The decision rests on whether the patients condition is considered a systemic illness with symptoms (moderate risk) or minor illness/injury (low risk). And, because the fever is not documented, the chart would lean toward the minor illness as the level of risk. Based on your presentation, the clinical documentation best supports a 99282.