Wiki E/M level 99283 vs 99284

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dawn1170

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pt. presents with ear pain and the final diagnosis is Otitis Media
MD does a comprehensive HPI and Exam and then only thing done was a prescription was written so now MDM is moderate.
According to my coders the level is now 99284 due to the documentation however, I disagree from prior coding experience I would code this a 99283.

Can any of you give me some insight on how to train coders in the decision to use code 99283 vs 99284? In our ED's the providers are very good at getting a comprehensive HPI and a comprehensive exam on about every patient that come in and the MDM is usually moderate due to prescriptions.

Any suggestions is greatly appreciated.

Thanks,
 
OverArching Criteria

Medicare tells us that the overarching criteria for all documentation is medical necessity. Is it medically necessary to have a comprehensive history and exam for otitis media? Probably not.

Therefore, you should more appropriately code 99283 for these visits.

This is a nebulous criterion, however. And it is a matter of judgment. I personally would code 99283, but if the documentation supports 99284 I wouldn't be able to state that the coder is wrong.

Clear as mud, I know ...

F Tessa Bartels, CPC, CEMC
 
I am in the same boat!

So happy to see I am not the only one with this issue. The doctors that need to document DON't and the one that does, does TOO much.
 
99284

FTessaBartels said:
Medicare tells us that the overarching criteria for all documentation is medical necessity. Is it medically necessary to have a comprehensive history and exam for otitis media? Probably not.
Therefore, you should more appropriately code 99283 for these visits.
This is a nebulous criterion, however. And it is a matter of judgment. I personally would code 99283, but if the documentation supports 99284 I wouldn't be able to state that the coder is wrong.

F Tessa Bartels, CPC, CEMC
Click to expand...

Hello Ms Bartels,
It would be easy to meet a 99284 as only a detailed history, detailed exam and moderate MDM is needed.
 
dawn1170 said:
pt. presents with ear pain and the final diagnosis is Otitis Media
MD does a comprehensive HPI and Exam and then only thing done was a prescription was written so now MDM is moderate.
According to my coders the level is now 99284 due to the documentation however, I disagree from prior coding experience I would code this a 99283.

Can any of you give me some insight on how to train coders in the decision to use code 99283 vs 99284? In our ED's the providers are very good at getting a comprehensive HPI and a comprehensive exam on about every patient that come in and the MDM is usually moderate due to prescriptions.

Any suggestions is greatly appreciated.

Thanks,
Click to expand...

Prescription drug management is only moderate RISK. Risk is only one component of MDM and you must have 2 out of 3. So if you have only the one dx and minimal to limited complexity of information your MDM is at best low complexity and many times straightforward. I have had many coders try to make the MDM lean solely on the prescriptions but that is not always correct.
 
I agree in our ED this would be a level 3. However, if they gave two different antibiotics, or a narcotic to a patient then we would code level 4. So we do somewhat (not totally) base our levels on meds given.
 
Medicare is clear that medical necessity is the overarching criteria for choosing an E&M level. Otherwise, all problems from straightforward to highly complex could be level 4 or 5. Providers should not game the system by performing more HPI and PE than is necessary for a simple problem. Most visits for otitis media are 99283 unless there are other documented complicating factors.
 
Rita Bartholomew said:
Medicare is clear that medical necessity is the overarching criteria for choosing an E&M level. Otherwise, all problems from straightforward to highly complex could be level 4 or 5. Providers should not game the system by performing more HPI and PE than is necessary for a simple problem. Most visits for otitis media are 99283 unless there are other documented complicating factors.
Click to expand...

You need to remember we are talking about emergency room visits here, where everyone is a new patient every visit. There are some but not many cases that are straightforward MDM. The pt has no history, no baseline, and may of "forgotten to mention" they have a cormorbid condition. So the order of the day is check everything that may be related to presenting problem. Pt could have a small case of cellulitis but combined with diabetes becomes more serious. Hence, simple problem could turn into the loss of a limb if not careful. The Docs I work for do not game the system, they simply work very hard for their money.
 
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