Diagnosis to Document and Those to Avoid Larry Halem, MD, CPC VEP Regional Productivity Director

E+M Levels There are 5 E+M levels (evaluation and management codes) Level 1 (99281): 0.6 RVU Level 2 (99282): 1.17 RVU Level 3 (99283): 1.75 RVU Level 4 (99284): 3.32 RVU Level 5 (99285): 4.9 RVU

Rules for your diagnosis The diagnosis you place can affect the E+M level applied to the chart The first diagnosis you document is the diagnosis that will code for the chart The others listed after can support complexity The first diagnosis should be the most complex of those listed

Rules for your diagnosis The broader the diagnosis the better The more differentials that fall below that diagnosis, the more complex the patient and the more risk assessed. The level of coding is based on risk

Diagnosis: What to Document Symptoms code well: focus on this as your first diagnosis Acute chest pain SOB Palpitations Acute abdominal pain with location  Fever versus simple diagnosis such as otitis media

Diagnosis: What to Avoid Avoid Urosepsis 1. Sepsis 2. UTI  Avoid diagnosis of Stroke or TIA as first diagnosis Document the symptoms: Slurred speech Left arm weakness

Diagnosis: What to Avoid Avoid Dizziness Are you feeling giddy because this is how this codes Instead document Near Syncope Avoid vertigo This also codes as giddiness Instead document peripheral or central vertigo

We are not Primary Care Physicians Do not bill primary care problems as the first diagnosis Hypertension bills poorly Document accelerated hypertension, hypertensive urgency, malignant hypertension, or hypertensive emergency Diabetes and Hyperglycemia bill poorly Document Diabetes out of control

We are not Dentist’s Avoid dental diagnosis Document symptoms Facial swelling Jaw pain

We are not a detox center Avoid documenting drug abuse as primary diagnosis Document symptoms such as palpitations or chest pain or document as a poisoning methamphetamine poisoning 

We are not psychiatrists Avoid psychiatric diagnosis as a primary diagnosis if possible Anxiety patient can be coded as 1.Palpitations 2.Anxiety Suicidal overdose 1. Intentional overdose 2. Suicidal gesture/ideation

Drunks aren’t that bad Avoid intoxication as your primary diagnosis If you sending labs it is better to bill 1. Acute delirium 2. Alcohol intoxication Remember to bill observation time if they are hanging out for more than 3 hours