E/M office visit coding series: Problems are the coding key

If you’re coding outpatient office visits based on medical decision making rather than time, the quickest method is usually to first determine the severity of the patient’s problems, i.e., “Did I just handle level 2, 3, 4, or 5 problems?” As discussed in the opening post of this series, if you address a level 3 or 4 problem and you do any kind of prescription medication management, then the overall visit level will match the level of the problems. It’s a quick and easy way to code a significant percentage of E/M visits.   

For coding purposes, problems addressed include only the health concerns you evaluate at that specific patient visit. You cannot include other diagnoses that you don’t address that day. You also cannot include problems that are managed exclusively by another clinician. But if the patient is seeing a cardiologist, endocrinologist, or nephrologist for a specific condition and you are prescribing and adjusting medications for that condition, then you are co-managing it and you may include it in your E/M coding.

Problems are separated into acute illnesses, chronic illnesses, and injuries. Identifying level 2 and level 5 problems is simple:

• A level 2 problem is a single minor, self-limited illness or injury (e.g., simple rash),
  
• A level 5 problem it must be an illness or injury that is life-threatening (e.g., severe chronic obstructive pulmonary disease [COPD], depressed skull fracture, or an acute asthma attack).
  

Everything in between (which is the vast majority of illnesses or injuries) is either a level 3 or level 4 problem. Here are some tips for figuring out which is which.

Chronic illnesses 

Primary care physicians spend a significant amount of time managing patients’ chronic illnesses. When determining the level of service for office visits involving chronic illnesses, here’s what to remember:

• One stable chronic illness is a level 3 problem, 
  
• Two (or more) stable chronic Illnesses is a level 4 problem,
• One unstable chronic illness is a level 4 problem. 

So what constitutes a stable chronic illness versus an unstable one? Chronic conditions (e.g., hypertension, coronary artery disease, asthma, obesity, or chronic kidney disease) are considered unstable for coding purposes if they are fluctuating, not at goal, not improving, elevated, worsening, or uncontrolled. Using these terms when documenting your assessment/plan (e.g. “HTN is elevated, losartan increased to 100 mg”) is a helpful signal to coders, auditors, or insurance companies to confirm that you performed level 4 work.  

Failing to clarify in the documentation that improving conditions are still not to goal can result in level 4 visits being incorrectly down-coded to level 3, resulting in significant loss of revenue. For example, “Diabetes is markedly improved” could signal a level 3 problem, while “Diabetes is markedly improved (A1C has dropped from 14 to 10) but still not to goal” makes it clear that this remains a level 4 problem. Similarly, “Depression improved” is a level 3 problem, but “Depression improved but still significant, increase sertraline to 100mg” describes a chronic condition that is not to goal or not controlled and, thus, a level 4 problem.

Acute illnesses

Identifying the problem level of chronic illnesses is relatively simple because there are often objective measures (e.g., A1C for patients with diabetes) to determine whether they are stable or unstable. It is slightly more subjective for acute illnesses, but the key factor is whether the illness, left untreated, would likely result in hospitalization or death.

When determining the level of service for office visits involving acute illnesses, here’s what to remember:

• Uncomplicated acute illnesses, such as urinary tract infections (UTI), sinusitis, or sore throat are usually level 3 problems. If you do not treat them, they will not usually result in hospitalization or death.
• Acute illnesses with systemic symptoms, such as pneumonia, colitis, or pyelonephritis are usually level 4 problems. These are conditions where there is a possibility of significant harm, including hospitalization or death, if the problem is left untreated or the disease progresses.

Injuries

Identifying the problem level of injuries is somewhat similar to acute illnesses.

• Uncomplicated injuries (e.g., simple ankle sprain) are level 3 problems,
• Complicated injuries (e.g., head injury with loss of consciousness) are level 4 problems.

This category is perhaps even more subjective than acute illnesses. If an injury requires you to order and interpret an x-ray to rule out fracture, is that a complicated injury? Many doctors would think so, but official guidance is vague. The American Medical Association’s definition of an “acute, complicated injury” is “An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity.” The example the AMA gives is a head injury with loss of consciousness, but obviously there are many other types of injuries that are difficult to compare to that. Hopefully more specific guidance will be provided in the future.

To identify problem levels more quickly, you can use this table:

— Keith W. Millette, MD, FAAFP, RPH

Posted on Nov. 29, 2022