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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. 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 

11. 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

12. 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