EM Coding Alert

Question: The provider performed an emergency department (ED) evaluation and management (E/M) service for a patient who was suffering from back pain. The E/M featured a detailed history, a detailed examination, and moderate-complexity medical decision making (MDM). The provider also ordered a magnetic resonance imaging (MRI) with contrast materials to pinpoint the problem. Final diagnosis was “discitis multi regions.” How should I report this E/M encounter? Do I need to report the back pain and the discitis?

Wisconsin Subscriber

Answer: You do not have to report the back pain since the provider reached a diagnosis by the end of the encounter. So, you’ll link M46.49 (Discitis, unspecified, multiple sites in spine) to the E/M code.

For the E/M, report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity…).