When a patient needs to see another physician besides the emergency room physician, the patient often has a complex medical problem. There are two emergency room evaluation and management codes that the only difference is the amount of history obtained and the extent of physical examination performed. These codes are 99283 and 99284. The level of medical decision-making capacity is the same. Both codes require moderate medical decision-making capacity.
The Current Procedures and Terminology book states to demonstrate the level of Moderate Complexity (MDM), two of the three following categories must be met. The categories are 1. multiple medical diagnosis or management options, 2. moderate complexity and/or amount of data to be reviewed, and 3. moderate risk of complications and morbidity and mortality.
Let us use an example of a patient who presents with a recent event of seizure like symptoms. The ER doctor asks the neurologist for an evaluation. The neurologist must differentiate and list the multiple medical diagnosis or etiology of seizure like symptoms. The neurologist has to review a moderate amount of data. The data can include a CT Scan, a toxic blood screen, and complete blood count with differential, and a Comprehensive Metabolic Panel. In this case even the third category can be met. The risk of complications from a seizure and the morbidity and mortality from and untreated or recurrent seizure is high.
The ER visit code 99283 requires an expanded problems focused history, an expanded problem focused exam and a medical decision making of moderate decision-making capacity. An expanded problem focused history requires a chief complaint, a brief history of present illness, and a problem focused review of system. Our documentation of the patient would state patient appears to have shaking and appeared to be out of it. It occurred today. The review of systems would address any current symptoms that would indicate the cause of seizures. The physician may ask if the patient has had recent fevers or chills. An expanded problem focused exam is defined as a limited exam of the affected organ system and another related system. In this case it would consist of an exam of the patient’s mental status and a neurological exam.
The ER visit code 99284 requires a detailed history, a detailed examination, and moderate medical decision-making capacity. A detailed history requires an extended history of present illness, pertinent past medical family and social history, a problem pertinent review of system and a few more systems. The history would be documented as stiffing and shaking of the body with apparent loss of attention, occurred today at 4pm, lasted for 20 minutes, shaking was severe. Patient denies, fevers, chills, sweats, chest pain, palpitations, nausea, and vomiting. The patient denies a history or seizures and drug use. The patient has HTN. There is no family history seizures. The patient works as an auto mechanic. A detailed medical examination extended examination of the affected body system and other symptomatic or related organ system. In this case a complete neurologic exam should be performed with testing all the cranial nerves, strength testing and reflexes. A complete mental status exam or psychiatric examination qualifies as a detailed examination.
You can see with a more extensive history and examination you can bill more for a condition with moderate decision-making capacity and make more money.