Wiki ED E&M Leveling: 99283 vs 99284?

[mragda]

Hi,

I would like to have your insights about this scenario:

DX: headache

history: comprehensive
exam: comprehensive
mdm: moderate

-visual acuity done, CT scan was done and Rx given no other complaints.
-no neuro checks/exam ordered or performed.
-discharged

Will this be a level 4 because of the CT scan? or just a level 3 because headache is the only presenting prob and dx?

Thanks.

 

[Lashel]

Hi,

I would like to have your insights about this scenario:

DX: headache

history: comprehensive
exam: comprehensive
mdm: moderate

-visual acuity done, CT scan was done and Rx given no other complaints.
-no neuro checks/exam ordered or performed.
-discharged

Will this be a level 4 because of the CT scan? or just a level 3 because headache is the only presenting prob and dx?

Thanks.

assuming that the documentation really does support the history, exam, and MDM as stated above. Then this would be a 99284. There is always the gray area of whether the presenting problem supported the level of services provided. I wouldn't hazard a guess unless I was looking at the entire record for that visit.

 

[mragda]

assuming that the documentation really does support the history, exam, and MDM as stated above. Then this would be a 99284. There is always the gray area of whether the presenting problem supported the level of services provided. I wouldn't hazard a guess unless I was looking at the entire record for that visit.

What if patient presented for resolved headache. Patient is well appearing, asymptomatic and CT scan finding was normal? Thanks.

 

[thomas7331]

What if patient presented for resolved headache. Patient is well appearing, asymptomatic and CT scan finding was normal? Thanks.

I agree with the previous post - if the documentation of History, Exam and MDM meet the requirements for 99284, that's the appropriate coding choice. If you're considering down-coding based on the presenting problem, you're essentially making a decision that some part of the physician's documented work was not medically necessary. Medical necessity is a clinical decision, not coding - if you feel that the physicians have done more than is necessary that's something you should discuss with your providers or your leadership and come up with guidelines as to when and how it's appropriate to step outside of the coding rules and assign a lower level. In my opinion, it's outside of the scope of coder training to 'disqualify' provider documentation as exceeding medical necessity - coders aren't generally trained to know what patient symptoms or history could pose increased risk and/or warrant more thorough examination or testing.

 

[Lashel]

What if patient presented for resolved headache. Patient is well appearing, asymptomatic and CT scan finding was normal? Thanks.

if that was all that was documented?? well appearing, asymptomatic, CT normal...if that was truly all that was documented you would not have a level 4 because you wouldn't have nearly enough history and exam.