ED Coding and Reimbursement Alert

Question: Please help me determine the level of E/M code for the following case. A patient presents to the ED complaining of being suicidal but denying any physical complaints. Nonetheless, the physician conducts a comprehensive history and comprehensive physical examination. The physician orders two labs, a blood alcohol level and a urine toxicology screen, both of which come back within the normal range. A consultation is obtained from a psychiatric social worker who, after an interview with the patient and a discussion by telephone with the psychiatrist, sends the patient home with orders for outpatient follow-up the next day. Does this visit merit a level-four or a level-five ED service code?

Nevada Subscriber  
Answer: There are a number of factors to consider in this case. However, it appears that it would easily justify a level-five E/M code (99285, emergency department visit).
 
First, the physician conducted and documented both a comprehensive history and exam, even though the patient said he/she had no physical symptoms. This was a sound clinical decision, since most psychiatric disease processes exhibit underlying physical causes. The history and exam allowed the physician potentially to uncover factors that may have prompted the alterations in personality.
 
Second, the medical decision-making (MDM) portion of the visit also indicates a level-five service. The patient was determined to be a threat to self or others, which falls into a high-risk category. The follow-up orders support the fact that further work and care are needed, which is also considered extensive MDM. Finally, the lab orders and call for consultation are considered moderate levels of MDM. It may be classified as a level-five service because you meet the documentation criteria of comprehensive history and physical, and MDM of high complexity.