Medical-Coding-Resources

EM coding still causes alot of questions

How to level?

Here is info from yesterday

JUST because there's enough documentation for a 99284 doesn't mean the service should be reported as 99284.

Medicare addresses this in Pub 100-4, Chapter 12, Section 30.6.1 (A) where it states that the volume of documentation is NOT the sole criterion on which the level of service is selected. While you need to have enough documentation to support the code ultimately billed, they say that it would not be appropriate to bill the higher level of code (supported by the documentation), when a lower level of service more accurately reflects the clinical necessity for the extent of the work up. CPT addresses this same concept when they stated (CPT Assistant, August 2006) that the nature of the presenting problem (the 4th of the 7 elements that makes up an E/M service) is provided for the E/M code descriptions to assist the physician in determining the appropriate code to bill for the service.

Kind of a quick "rough and dirty" measure of whether you should consider a given encounter as a "low moderate complexity" visit (99283) or a "high moderate complexity visit (99284) is to look at the left hand column in the table of risk. For example, if you'd classify the encounter as "an acute uncomplicated illness or injury", there would have to be something pretty unique (ie - unusual or more complex) about the clinical presentation to say that that should be a 99284 service --- EVEN IF the doctor has given the patient prescription medication. Obviously this isn't a hard and fast rule. But if you're having a hard time deciding whether a documented 99284 should really be reported as 99283, looking at that left hand column of the table of risk might give you a bit of a measuring stick by which to figure out which is the more appropriate code to report.

Hope this helps!

Joan Gilhooly,