Wiki Pediatric Emergency Medicine Physician Coding

[queeniek]

Moderate MDM in the ED can be 99283 or 99284. I'm looking for guidance on how to determine which is the appropriate level.

 

[thomas7331]

The level is assigned based on history and exam in addition to MDM. Although both codes require the same moderate level of MDM, 99284 also requires a detailed history and exam, whereas 99283 requires only an expanded history and exam.

 

[queeniek]

The level is assigned based on history and exam in addition to MDM. Although both codes require the same moderate level of MDM, 99284 also requires a detailed history and exam, whereas 99283 requires only an expanded history and exam.

I understand that portion, I'm curious about those that have a detailed or comprehensive history and exam. When it truly comes down to MDM, how to do you decide what is low/moderate vs moderate/high? For example:
3 points for # of Dx and/or treatment options (new patient with no workup)
2 points for amount and/or complexity of data (history from mother)
Prescription for Zofran
Final Impression: Patient well appearing and in no distress. Gastroenteritis

99283 or 99284?

 

[thomas7331]

I understand that portion, I'm curious about those that have a detailed or comprehensive history and exam. When it truly comes down to MDM, how to do you decide what is low/moderate vs moderate/high? For example:
3 points for # of Dx and/or treatment options (new patient with no workup)
2 points for amount and/or complexity of data (history from mother)
Prescription for Zofran
Final Impression: Patient well appearing and in no distress. Gastroenteritis

99283 or 99284?

I'm not sure I'm understanding your question. MDM is determined the same way for these codes as for any other E&M codes. If your encounter is ranked as low MDM, then the code assignment would be 99282, not 99283, because 3 of 3 components must be met or exceeded. The only difference between 99283 and 99284 are in the history and exam portions since MDM must be moderate or higher for both of these.

In your example above, per the standard audit tools, this would qualify as moderate MDM because you have 3 points for the diagnosis with a new problem, and moderate risk for the prescription drug. However, you'll need to take into consideration your payers' policies and your organization's internal guidelines (if any) because MDM tends to be a subjective area and some payers and providers will consider a single presenting problem with no complications that is treated with a prescription drug to be low MDM rather than moderate.

 

[queeniek]

Our internal guidelines are to use standard audit tools, which leads us to 99284 in that scenario. However, we have a payer that is not in agreement with us. I 100% agree about the subjectivity and that is what I was curious about....how does one decide and/or argue their case about it without written guidelines on how it was determined - other than standard auditing tools.
Thanks for your help!

 

[thomas7331]

If the documentation supports a level 4, the payer is most likely taking the position, based on medical necessity, that the nature of the presenting problem only supports a level 3 service. That would not surprise me, given that auditors understand that the history and exams these days are set up pretty much as templates to give the maximum level for those two areas, whether or not the presenting problem warrants it. You can argue your case based on the coding guidelines, or have the provider write an argument for the medical necessity and clinical need of the higher level of service given the patient's symptoms, but it may not be worth the effort to fight it.

My approach has usually been to always at least appeal these once if I feel the documentation supports what was coded because the payer needs to know that providers will push back on these determinations if they are not justified.

 

[Cynthia Hughes]

I understand that portion, I'm curious about those that have a detailed or comprehensive history and exam. When it truly comes down to MDM, how to do you decide what is low/moderate vs moderate/high? For example:
3 points for # of Dx and/or treatment options (new patient with no workup)
2 points for amount and/or complexity of data (history from mother)
Prescription for Zofran
Final Impression: Patient well appearing and in no distress. Gastroenteritis

99283 or 99284?

One thing you may look at is whether there should have been a diagnosis of dehydration since Zofran is used in viral gastroenteritis when the child is moderately to severely dehydrated or cannot tolerate oral rehydration with electrolyte solutions (e.g., Pedialyte). Moderate to severe dehydration in a small child increases risk of hospitalization. This may not be the case here (unless the child improved significantly during the visit) since the final impression is well-appearing and in no distress. However, it is important to consider manifestations that increase the complexity of the visit.

Hope that helps.
Cindy