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99283 or 99284 for ankle injury?

(2 posts)
  • Started 6 years ago by KennaDoyle
  • Latest reply from ERcoder
  1. KennaDoyle

    A patient presents to the ER with a ankle injury, the physician orders an x-ray, interprets the x-ray and determines that the patient has a sprain. Orders a wrap for the ankle and sends the patient home with one Rx for pain. We have some coders stating this would be 99383 and others stating it would be 99284. One coder states that the risk is moderate per CMS guidelines and therefore should be a level 4.

    Posted 6 years ago #
  2. The problem you mention is becoming more common. As physicians are educated on documentation requirements and as more ED's are using templates, prompted dictation systems or EMRs, it is increasingly more important that a coder with experience in emergency medicine is involved in the code selection for the physician services.

    Selecting a ED E&M is not as plain and simple as an audit sheet makes it out to be. The determining factor is medical necessity which in coding is best defined by the Nature of Presenting Problem (NOPP).

    CPT does address the nature of presenting problem when describing the levels of service. In your example you mentioned deciding between a 99283 or 99284. The NOPP for these is:
    99283 - Usually, the presenting problem(s) are of moderate severity.
    99284 - Usually, the presenting problems are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.

    If you feel that your patient's NOPP was of high severity and requires urgent evaluation by the physician then by all means go with the 99284 (if you have the Hx, Ex and MDM to back it up). But if the NOPP does not seem to fit you may want to look a little lower. As Johnny Cochran might say "If the NOPP doesn’t fit, Level 4 ain't it"

    You can also compare your presenting problem to the clinical examples in CPT. While it is not an extensive list, it will help you gauge the type of presenting problem that AMA feels would fit a level of service. If we compare your scenario to the clinical examples from CPT it looks to be an exact match to:

    99283 - Emergency department visit for a patient with an inversion ankle injury, who is unable to bear weight on the injured foot and ankle.

    For a routine sprain vs. fracture type extremity injury the level is probably going to being a 99283 regardless of x-rays or not, prescriptions or not, injections or not unless there is something to indicate that the presenting problem is more consistent with the high severity NOPP needed for a 99284. That indication may be the mechanism of injury i.e. fall from a high place or MVA where the EDMD would be required to do a complete head to toe evaluation or the severity of the injury where there may be an ortho consult for surgery or sedation to reduce a fracture or dislocation.

    A coder cannot simply calculate the points without consideration to the nature of presenting problem (NOPP) and medical necessity of the encounter. My experience has been that without considering NOPP 90% of ED visits could code as 99284 or higher.

    The CMS correct coding policy does address medical necessity and E&M services. "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."

    I hope this helps. Feel free to contact me if I can be of more assistance.


    Todd Thomas, CPC, CCS-P Click here to e-mail me
    ERcoder, Inc
    941 NW 164th, Suite 1, Edmond, OK 73013
    (405) 749-2633

    Posted 6 years ago #

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