Not all emergency surgery should be coded at the highest level | E/M Services and MDM

Surgeons sometimes think that the E/M service on the date of every emergency surgery is the highest level E/M.  99285 for an ED evaluation or 99223 for an inpatient initial service.  This article describes medical decision making (MDM) using the 1995 and 1997 documentation guidelines. .  In 2021, 99202–99215  have a different set of guidelines. However, the E/M service for  emergency surgeries is  performed in the hospital most frequently, and we don’t expect those guidelines to be updated until 2023.

When I teach E/M level in general surgery, few topics cause as much disagreement as what level of service the surgeon can bill for the E/M service for a patient before emergency surgery.

Of course, the first task is to select the correct category of code.  Or, as one physician said to me, “Just tell me what to bill and I’ll bill it.”  This article will walk through two examples, acute appendicitis and small bowel obstruction and assign the medical decision making (MDM).

First, let’s review the key points of MDM 

Remember, this article relates to the 1995/1997 guidelines, not to codes 99202–99215 in 2021.

• There are four levels of MDM: straightforward, low, moderate, and high.
• Selecting the correct level requires two of three elements.
• The three elements are: 1) number of diagnoses or treatment options, 2) amount of data that is reviewed, and 3) morbidity and/or mortality from the table of risk of the presenting problem, diagnostic tests ordered or treatment options selected.

The first two elements have “points” assigned to them in audit sheets.  These points were developed by the Marshfield Clinic, after the Documentation Guidelines were released.

Click on an image below for expanded details of the three elements and the table of risk, or reference the Medical Decision Making article from Everyday Coding.

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