tci ED Coding & Reimbursement Alert - 2003 Issue 7

You Be the Coder: When You Cant Get MDM to Add Up

Question: A 20-year-old patient presents to the ED with a fever of 105 and body aches. The day before, he went to his regular physician, who prescribed an antibiotic. The documentation seems to warrant only a level-two E/M code (99282), but I don't feel this is sufficient. The problem is that the documentation shows a detailed history and detailed exam, but the only treatment done in the ED was lab work. The physician neither gave medication to the patient nor sent him home with any. Should we report this case as 99282 because of this low-level medical decision-making? ...

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