Decision-making Involved in Vertigo Differential Diagnosis Determines E/M Level
Published on Thu Feb 01, 2001
Vertigo, or dizziness, can have many potential diagnoses, but otolaryngologists should not bill new office visits or consults with vertigo patients at a predetermined evaluation and management (E/M) level or assume that such visits automatically reach a level four or five. Levels of such visits can vary dramatically depending on the differential diagnosis and the treatment options, tests (both ordered and reviewed) and risk that flow from it.
Although the otolaryngologist may perform a comprehensive history and physical (H&P) when seeing a new vertigo patient (i.e., qualifying for a level-five E/M service), the visit as a whole may not exceed a level two or three because the medical decision-making (MDM) does not support a higher claim. On the other hand, the MDM may reach high complexity, which, in conjunction with a comprehensive H&P and proper documentation, allows a level-five visit to be paid.
The level of MDM for vertigo is determined principally by the differential diagnosis, which can vary significantly from case to case. Dorlands Medical Dictionary defines differential diagnosis as the determination of which one of two or more diseases or conditions a patient is suffering from, by systematically comparing and contrasting their clinical findings.
When the physician first sees a vertigo patient, the differential diagnosis may include dozens of potential diseases or conditions, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPTs editorial panel and executive committee. Differential diagnoses will differ based on the history the otolaryngologist documents. When I take a history, Im already developing possible diagnoses for the problem. As I learn more about the patients history, the number of differential diagnoses narrows, Eisenberg explains.
While attempting to pinpoint the diagnosis, the number of questions the otolaryngologist asks the patient almost invariably raises the history to a comprehensive (highest) level. By the time the otolaryngologist examines the patient, he or she may already suspect a possible diagnosis. And because vertigo patients typically present with few if any physical symptoms, the exam although extremely thorough and therefore qualifying as a comprehensive single-system ENT exam will likely be normal and confirm the otolaryngologists hypothesis of the cause of the condition or disease.
Determine the Level of MDM
For outpatients (including new patients), there are four MDM levels straightforward, low complexity, moderate complexity and high complexity corresponding to a particular level E/M code. Level-one and -two E/M codes, for example, require straightforward medical decision-making. Level-three codes require low complexity, while level-four codes require moderate complexity, and level-five codes require high complexity.
Note: Inpatient E/M codes have only three categories: low, moderate and high.
To calculate the correct level of MDM, three factors must be considered:
Number of diagnoses [...]
