Category:
Coding and Billing
In physician documentation training sessions we have been discussing the importance of documenting differential diagnoses in lower acuity cases. Patients who present with high risk complaints commonly support 99285 services. However, many patients for whom a lower risk condition is concluded receive care consistent with a 99284 when the medical decision making is clearly documented. Documenting differential diagnoses on lower acuity patients can make the difference between a 99283 and a 99284. The payment, when calculated in RVUs, represents an 86% difference.
Of course, a good history and physical exam are often the best route to a correct clinical conclusion, regardless of the tests or interventions ordered. But, unsympathetic reviewers are not willing to concede just from the H&P that you were considering things other than the final diagnosis unless you tell them. For example, stating “child is taking juice without a problem” might mean to you that you have considered dehydration and are concluding that it is unlikely in this case but payers will not conclude that from the exam finding alone.
Medicare documentation guidelines clearly indicate that “the number and types of diagnostic tests employed may be an indicator of the number of possible diagnoses.” “…other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity and/or mortality should be documented.”
While tests indicate possible diagnoses, exam results are not given the same weight by payers. Differentials remove all doubt about what your thoughts were at the time and add the risks associated with the likely conditions to the decision to code a 99284 versus a 99283. CPT relies on risk to help select the correct E/M service level: “Medical decision making refers to the complexity of establishing a diagnosis… as measured by… the risk of significant complications… as well as comorbidities associated with the patient’s presenting problem(s)...”
Case Examples Where Differentials Make All the Difference
For example, consider a 4 year-old with a 2 day cough and a history of fever presenting at 102.1 with a final diagnosis of URI after a good physical exam and chest x-ray. He is given Motrin and a precautionary Z-pak script. The chest exam is clear bilaterally, no rales, wheezing, rhonchi, inspiratory stridor or retractions and no flaring. Neck exam mentions “no meningismus”. Clearly, pneumonia and meningitis were considered but if never mentioned payers will not consider them when determining the level of MDM complexity. With no labs and no documented risks, most coding experts would assign this a 99283 service level. By documenting your conclusion that pneumonia was possible but not present, you would have supported a solid 99284 service even if you had discussed but ultimately decided against the x-ray.
Consider also a 42 year-old with more frequent seizures the last few months who last had his medication adjusted 3 years ago. He is a diabetic and had a 2 minute seizure before ED presentation but is normal now. The process of concluding that all he needs is a medication adjustment is complex, ruling out infection, recent trauma, diabetic complications and other possible causes. In a primary care setting where the patient was well known to the provider, the physician might be quite comfortable limiting the history and exam to focus principally on the medication. In the emergency care setting, your thought process must range into other quite concerning causes and should be documented when applicable. Depending on the patient’s history and seizure medication, it’s quite possible that no laboratory or limited laboratory workup will be done, despite a higher level of MDM.
Abdominal pain in the emergency department most often presents with a wide array of potential causes and most of these are of considerable concern to the emergency physician. Yet, when there is no discussion of your thought process, an unsympathetic reviewer is unlikely to conclude that you were attentive to the possibility of appendicitis, ischemic bowel, PUD, pyelonephritis, AAA, etc. Not every abdominal pain patient has the likelihood of these conditions, but when they are likely, you must mention them.
The decision not to obtain certain tests, such as a CT when it might not be possible, should always be documented as this can add weight to the complexity of decision making. When a test is preferred but precluded by other conditions or circumstances, like the mother asking not to have her child exposed to more radiation, your thought process becomes your deciding factor and you should be given credit for the added complexity of working without all the tools you would like to have. EGO will give equal weight in the coding process to your decision not to order a test if the reason is clear and clinically indicated.
Presenting problems with benign outcomes that commonly are reported as 99283s, without labs/studies, where differentials can support a 99284 include:
– Flu
– Fever
– Cough as bronchospasm
– Abdominal pain as gastritis or EGR
– Shortness of breath or wheezing as URI
– Low back pain
– Vertigo
– Chest pain
– Headache
These and others like them can involve disease processes that either mask higher risk conditions, such as pneumonia masquerading as the flu, or are commonly associated with higher acuity conditions, like chest pain or shortness of breath. Of course, don’t make the case more complicated than it really is. Not all patients presenting with such symptoms involve higher risk differentials. But, when they do and the clinical conclusion is benign, having the record reflect your concern for the possibility of these more risky diagnoses supports the claim at levels higher than a 99283.
“Think in Ink” for Higher Levels of Care
For evaluation and management services, you are paid principally for your thought processes. For good reason, Medicare calls E/M work a “cognitive service”. They recognize that thought process and the complexities of establishing a diagnosis have long been undervalued in the payment system. Most of the coding industry distinguishes a 99283 from a 99284 principally from the number and types of tests and interventions ordered. EGO believes that a clinical approach to coding allows more than tests or interventions to identify the higher risks in certain presenting problems and when lower acuity conclusions are reached we will report 99284 services if the potential for higher risk conditions are made clear by the documenting physician.
Hitting the history and exam bullet points was never a very good way of quantifying the value of an E/M service. The new payment paradigm is likely to require more documentation of the value of decisions and how you reached them. “Thinking in ink”, including documenting differential diagnoses on lower level acuity cases, increases the value of your record to other care givers and provides proof of work associated with the higher levels of care.
Work with your physicians to assure that they document these important considerations in lower acuity patients. The sheer volume of such patients in an average ED will significantly impact revenue when you turn under-documented 99283s into 99284s or 99285s by clarifying medical decision making.
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