Wiki Emergency Room E/M coding Question.


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Does anyone have an ideas as to what to code when documentation on an ER note does not meet the lowest level E/M cpt code. 99281 requires 3 out of three levels to be met. There is no exam and no MDM. I would think that it wouldn't be billable at all.

It is a regular note, that just doesn't have enough documentation to warrant an exam or MDM. The patient is fine. For example in the case of Inpatient admits, if the levels are not met, we usually default to a subsequent visit. What is the case in the ER when the three levels (HPI, EXAm And MDM)to warrant a level one are not met?

Two choices:

A.) The facility bills for an E/M because their portion is sufficient; the provider gets nothing.

B.) The facility bills for its E/M and the provider gets an unlisted E/M CPT code.

(I realize what a can of worms unlisted codes open, hence choice "A"!)
A hospital near here is actually hiring a coder to just get documentation from ER docs. Because the ER docs are salaried employees of the hospital, the docs get paid no matter how inadequate their documentation is. And the situation that has happened here happens all the time. So some poor coder is going to have to go around and hassle these docs into doing their job.

"What was the length of the laceration? Was it a layered closure?"

"What was the level of history? What examination was done?"

All this just so the hospital gets reimbursement for what was actually done. I would actually query the physician. If it is an ER visit, you can bet that the minimum required of the lowest level of E/M service was performed. Otherwise they would be unable to declare that the patient was "fine".

This is doubly true if you are trying to get reimbursement for a private physician.

I would try to get adequate documentation and then proceed.