Wiki 99283 rationale question

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jmlarzzaapc

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We are working with a group that believes if a patient is seen in the Emergency Department by a provider for any COPA, other than one (1) self-limited/minor problem, that the level of service is a 99283 if data and risk are both minimal/straightforward. We have advised that a 99282 is supported in this scenario for any presenting problem if no other MDM elements are met to support the 99283. Has anyone else seen this in practice and have any official guidance from CMS, a MAC, the AMA and/or ACEP to support this? And how would you defend this for a payer denial without having 2 of the 3 MDM elements supporting a 99283?
 
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You are talking provider and not facility, correct?
ACEP has a good Q&A on it.

Do you have an example where the COPA is low or higher where they did not meet it in one of the other columns? They would still need to meet 2/3. In most cases, they are probably going to make it to at least a 3 unless there was absolutely nothing done, but that would be weird in the ED. Unless it is where someone routinely uses the ED like a PCP and comes in for a stuffy nose or something and they tell them to take allergy OTC meds, use a humidifier and send them on their way. It would have to be really, really simple. Or, they showed up with nothing wrong other than they just wanted a Covid swab or something, and it was negative. If it is a child with a guardian/parent, you are going to automatically make it to 3 just by the independent historian factor.

If it truly did not meet 2/3 it is not 3. I am guessing they are probably basing it on the fact that it would be rare to see absolutely nothing done to meet one of the other 2. I would say a 2 is not very common in all of the ED docs I have reviewed.
 
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amyjph said:
You are talking provider and not facility, correct?
ACEP has a good Q&A on it.

Do you have an example where the COPA is low or higher where they did not meet it in one of the other columns? They would still need to meet 2/3. In most cases, they are probably going to make it to at least a 3 unless there was absolutely nothing done, but that would be weird in the ED. Unless it is where someone routinely uses the ED like a PCP and comes in for a stuffy nose or something and they tell them to take allergy OTC meds, use a humidifier and send them on their way. It would have to be really, really simple. Or, they showed up with nothing wrong other than they just wanted a Covid swab or something, and it was negative. If it is a child with a guardian/parent, you are going to automatically make it to 3 just by the independent historian factor.

If it truly did not meet 2/3 it is not 3. I am guessing they are probably basing it on the fact that it would be rare to see absolutely nothing done to meet one of the other 2. I would say a 2 is not very common in all of the ED docs I have reviewed.
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Thank you so much for your response. We do apply the guidance in the ACEP FAQs for this group. When we look at these encounters, there are truly no data and or risk elements documented by the provider. If it was a peds patient, of course we would count the independent historian, but for these encounters, these are adults and there are no data elements and or risk items. To me it is a physician documentation issue and not a coding matter as we are applying the 2 of 3 MDM guidance.
 
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jmlarzzaapc said:
jmlarzzaapc said:
Thank you so much for your response. We do apply the guidance in the ACEP FAQs for this group. When we look at these encounters, there are truly no data and or risk elements documented by the provider. If it was a peds patient, of course we would count the independent historian, but for these encounters, these are adults and there are no data elements and or risk items. To me it is a physician documentation issue and not a coding matter as we are applying the 2 of 3 MDM guidance.
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Yes, are they just poor at documenting what they are doing? Do you have an example? If that really is all the documentation and the data and risk are not meeting it, that's it. I mean, the official guidance is the CPT E/M guidelines. They can argue all they want but just saying it doesn't make it real :) :). I bet as you said, they are not documenting everything or missing something.
 
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