Wiki ER Visit

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KaylaRieken

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I code for urology and we get asked to come to the ER to see patients. If my doctor does a comprehensive exam and history, and sees the patient for kidney stones and reviews labs, a CT image, and report, but suggests the patient to pass the stones would this be a 99283 or 99284? The ER doctor had all these tests done before they asked the urologist to come see the patient. I get confused on what code to give because in the code description it says for the 99284 usually the presenting problem(s) are of high severity, and require urgent evaluation by the physician. But by the time our physician seen this patient, I wouldn't consider this a high problem and they are managed with pain medication already. Any suggestions would help. ER coding is a little confusing to me.
 
Hi Kayla. As an auditor with specialty knowledge in urology, I would agree with you that your urologist is seeing a patient with an acute illness, but not one that is high risk, meaning that it doesn't fit the high risk MDM description of: "may pose a threat to life or bodily function,e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure." However, you should look at the key components: you're at comprehensive hx and comprehensive exam, which would support 99285 is MDM were high. But MDM is moderate. 99283 and 99284 both need moderate MDM, but 99284 is comp hx and exam, so if you really do have documentation of both, that code fits.

That said, be sure the documentation supports moderate MDM. With no Rx drug management, I would tend to consider this low MDM (based on your question, without seeing the notes) - low risk for 1 acute uncomplicated illness, 3 pts for number of dx/mgmt options (1 new problem with no additional workup planned), and 2 pts for data for the lab and CT reviews. That adds up to low MDM which would only support 99282. If there is mention of systemic symptoms, then it would bump to moderate risk and moderate MDM, supporting 99284.

Hope that helps!

Leesa A. Israel, BA, CPC, CUC, CEMC, CPPM, CMBS, AAPC MACRA Proficient
Head of Publishing, Editorial & Technology
AAPC
 
So in this case provider is reviewing lab 1 pt, reviewing the ct report 1 pt, and reviewing the ct images 2 pts. So in this case 99284 would be appropriate? If they did prescribe a medication to pass the stone, 99284 would be appropriate too? The whole presenting problem (s) are of high severity, and require urgent evaluation by the physician really throws me off even when they have the appropriate documentation.
 
KaylaRieken said:
So in this case provider is reviewing lab 1 pt, reviewing the ct report 1 pt, and reviewing the ct images 2 pts. So in this case 99284 would be appropriate? If they did prescribe a medication to pass the stone, 99284 would be appropriate too? The whole presenting problem (s) are of high severity, and require urgent evaluation by the physician really throws me off even when they have the appropriate documentation.
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Correct. If MDM is moderate, which both of those scenarios are, then 99284 is supported. Stick with counting the key elements rather than focusing on the wording in the code descriptor. The code descriptor uses the word "usually" as well, so don't let it throw you too much. Code based on the key element levels and how they come together -- that's what an auditor will do. Medical necessity is key, too, so if the provider is doing comp hx and exam just because and they aren't warranted, you don't want to overcode, but MDM and medical necessity of the problem support 99284 in this case, I believe.
 
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