ED Coding and Reimbursement Alert

Question: A 22-year-old patient came into the emergency room with abdominal pain and vomiting, with no prior history. Her history and physical exam are comprehensive. The physician completed lab work, administered a phenergan intravenous, and sent the patient home with a prescription for phenergan with no instructions to return for follow-up care. How should I code this?
      
Georgia Subscriber

Answer: With a comprehensive history and physical exam, the medical decision-making (MDM) component may drive the code choice for this case. When determining the MDM level, you should consider that the problem is new to the examiner, with no additional workup planned, and limited points for data. You should also take into account that there is moderate risk associated with a new problem with an uncertain prognosis, administration of intravenous medications, and prescription drug management.
 
The emergency department codes from the 9928x series that are consistent with moderate MDM -- the level that is appropriate in this scenario -- are 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity) and 99284 (... a detailed history, a detailed examination, and medical decision-making of moderate complexity).