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I need E/M expert. PLEASE. ?????

  1. Default
    Medical Coding Books
    I find it a little "disconcerting" that you are doing internal auditing and then in the same breath stating that "I have heard from some that pharyngitis or cough with URI are too weak of a diagnosis......" That statement makes no sense to me. As the previous post suggested, the documentation either meets the criteria for a level 4 or it doesn't.

  2. #12
    Milwaukee WI
    Default Nature of Presenting Problem
    Check 2008 CPT Professional Edition, begining on page 3 under "Nature of Presenting Problem."
    I would characterize pharyngitis as "self-limited or minor"

    Now go to page 5-6 under "Instructions for Selecting a Level of E/M Service" and you'll note on page 6 under "Review the Level of E/M Service Descriptors and Examples in the Selected Category or Subcategory," the last paragraph in this section reads:
    "The nature of the presenting problem and time are provided in some levels to assist the physician in determining the appropriate level of E/M service."

    Now go to page 10 and find the descriptions of Established Patient Office Visits ...
    Under 99212 it states: "Usually the presenting problem(s) are self limited or minor."
    Under 99214 it states: "Usually, the presenting problems(S) are of moderate to high severity."

    This is why you might be told that Pharyngitis is a "weak diagnosis" for a level 4 visit, even when the documentation meets all the bullet points for that level.

    F Tessa Bartels, CPC, CPC-E/M
    Last edited by FTessaBartels; 08-06-2008 at 04:55 PM.

  3. #13
    Default EM Level
    I agree. Code the documentation. Use the E/M guidelines. It is black and white. CPT states specifically what is required to determine the level of service. Any rx makes the MDM=moderate. It is what management risk the physician is performing. We as coders cannot determine that pharyngitis is a "weak" diagnosis, the physician's level of risk for his medical decision making is considered moderate for non-parenteral controlled substances.

  4. Default
    We have a place called Medisync come in to educate our physicians on coding. They are telling the physicians that something like pharyngitis would always come out to a 99214 when audited, if a prescription is given. They say that the exam that would have to be done, along with the presciption that is ordered (which is moderate decision making) will always come out to a level 4 visit. If there are no other conditions present that is putting the patient at risk, or no presciption is given then a level 3 would be appropriate.

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