Primary Care Coding Alert

Question: One of the primary care physicians (PCPs) I work for documented a visit: a 78-year-old patient with several differential diagnoses who presented for diarrhea, which they have been experiencing for seven days, along with dizziness for five months. The provider wrote that they performed a physical exam but did not have the ability to run labs in-house and so discussed going to the emergency department (ED) with the patient and their spouse due to extensive comorbidities. They both agreed that he would go to the ED for further care and testing. The only diagnosis listed for the visit is R19.7. Can I code this at the highest level of evaluation and management (E/M) services because the patient went to the ED?

California Subscriber

Answer: In this situation, it’s important to look at the documentation for this specific visit. The complexity of this case is implied by the provider’s phrase “extensive comorbidities,” but do they specify which comorbidities? Are there any other diagnoses listed in the chart, especially for this visit encounter? If acute diarrhea is a particular concern due to a specific differential diagnosis, then you may have evidence of more complex medical decision making (MDM), which can bump up your E/M leveling. However, the only diagnosis you mention the provider recording is R19.7 (Diarrhea, unspecified).

The American Academy of Family Physicians (AAFP) offers guidance on situations where the provider suspects several variables are at play and wants to code a higher level of E/M services, saying: “The level of service reported must be supported by total time personally spent by the physician on the date of the encounter or MDM. The number and complexity of problems addressed at the encounter is only one element of the MDM table. When selecting the level of service based on MDM, two of the three elements must be met or exceeded.”

So, for this visit, make sure you’re reporting an E/M code based on the documentation of services provided and time spent during this specific visit. Sending a patient elsewhere for a higher level of care implies that a condition may be complicated or severe but does not actually show that the PCP has provided E/M services that would meet the criteria for level 5.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC