Evaluate MDM for Acute Symptoms With Tests Ordered
Question: An established 46-year-old patient presented to the primary care office reporting vomiting and diarrhea for three days. The provider’s note documented eight episodes of watery diarrhea in the past 24 hours, four episodes of vomiting, nausea, mild diffuse abdominal cramping, no blood in stool, no recent antibiotics, and no recent travel. The exam showed dry mucous membranes and mild tachycardia. The provider ordered a basic metabolic panel, prescribed ondansetron, gave oral rehydration instructions, and told the patient to go to the emergency department if symptoms worsened or signs of dehydration developed. The provider documented 34 minutes of total time on the date of the encounter and diagnoses acute gastroenteritis with mild dehydration. Which encounter and diagnosis codes are appropriate? South Carolina Answer: Report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) based on the documented 34 minutes of total time on the date of the encounter. The documentation may also support moderate medical decision making (MDM) based on the acute illness with systemic symptoms/mild dehydration, lab order, and prescription drug management, but the documented time alone supports 99214 if payer rules allow time-based selection for evaluation and management (E/M) services. For the diagnoses, from the information you’ve provided, K52.9 (Noninfective gastroenteritis and colitis, unspecified) may be appropriate if noninfective cause is supported. However, this is a query opportunity, as knowing whether the condition is infectious or noninfectious is important for accurately capturing the patient’s condition. You can also report E86.0 (Dehydration) because the provider documents and addresses mild dehydration. Do not separately code vomiting, nausea, or diarrhea, as those symptoms are integral to the documented gastroenteritis. Remember, report symptom codes only when the provider does not establish a more definitive diagnosis for the encounter. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC 
