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ER Pro Fees

  1. #1
    Default ER Pro Fees
    Medical Coding Books
    I need some back up in order to help prove a point to my supervisors (who are not certified coders by the way).

    I do pro fees for the ER. I had a patient come in with cellulitis and they received an injection of antibiotics. She claims that since the pt received a shot (or there was a break in the skin done by us, as she calls it) that it is automatically a level three.

    So, correct me if I am wrong, but for starters, an ER visit needs 3 out of 3 components, right? Plus, there was barely a physical exam at all, no ROS and no social hx done. So wouldn't it have to be dropped down? I am correct in this, right? I'm not sure how to tell her that I don't agree. Any help or back-up would be appreciated.

  2. Default
    where I work an injection is normally a level 4 BUT you have to have the documentation to back that up. You need a full HPI, at least 2-9 ROS and 5-7 systems.......

    For a level 3 you only need one ROS and 2-4 body systems...

  3. #3
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    I do not see how you can automatically assume an injection is a physician level 4. You still have to get MDM and that is not always moderate even with the injection. Risk is only one component of MDM and sometimes , often in fact I have read documentation that does not get much above straightforword, they have one dx and very minimal complexity so since you must have 3 out of there it could very well be a level 1 or a 2.
    So the same is with Leslie's example she has virtually no hx at all which will bring the level down to a 1 and with what she has presented there is very little wiggle room for that.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Default
    Leslie, you are absolutely correct. You still need to meet the level with the applicable number of components for ED pro fee billing. Although the shot or "breaking of the skin" may be a level 3, low complexity as far as the MDM is concerned...but both the history & exam will still need to be at an EPF level in order to correctly assign 99283. You can reference your CPT manual to prove this or better yet pull the audit sheet for your Medicare carrier in your state and break it down for your supervisor that way.
    Corella Lumpkins CPC, CPC-I, CCS, CCS-P

    "High achievement always takes place in the framework of high expectations"

  5. #5
    Default
    Thanks Deb and Corella!!

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