ED Coding and Reimbursement Alert

Question: We regularly see these two diagnoses:

- dental pain, abscess, no tests, discharged with antibiotic and Percocet

- otitis media, no tests, discharged with antibiotic.

Supposing we have all the necessary documentation for the highest appropriate E/M level, should I report a level two or a level three? Would you explain why?


Oregon Subscriber


Answer: For these typical presentations, 99283 (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 moderate complexity) will usually represent the correct code choice, assuming adequate documentation is present.

While you shouldn't assume that the presence of a prescription automatically translates into 99283, that is often the case. And because these do not sound like urgent presentations, you probably don't have a nature of presenting problem consistent with 99283.

Remember: The difference between the documentation requirements for 99282 (... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity) and 99283 is medical decision-making (MDM) of moderate complexity.

Although prescription management suggests moderate risk, two of the three categories of MDM and three of three categories of history, physical exam, and MDM must meet or exceed the final level of service assigned.

Reader Questions and You Be the Coder reviewed by Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI in Stoneham, Mass.