Coding & Documentation

The short answer is that while an emergency referral does not preclude a visit from being high risk for purposes of MDM, it also does not ensure that the visit is high risk. This is a bit of a gray area that CPT will hopefully clarify in the near future. CPT is clear that the “risk” portion of MDM-based coding refers to the risk of complications and/or morbidity or mortality of the clinician's patient management decisions, not the risk of the patient's problem. But logically, there is some overlap between the two.

Determining the risk of management (i.e., treatment or diagnostic options considered and either selected or not selected) requires clinical judgment regarding the risk of long-term illness or functional impairment or organ damage that may result from treatment/management decisions made as part of a visit. CPT instructs that risk is based on the “usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.” CPT further states that clinicians have a common understanding of what constitutes minimal, low, moderate, and high-risk management in these situations and “do not require quantification for these definitions.”

In the absence of quantification, family physicians are left with the subjective task of determining how other family physicians would categorize the risks of the patient management decisions they make. In the scenario you describe, you must consider what the risk is to the patient of your referral decision, not the risks the patient faces from the management decisions another clinician may make at the next encounter.

(For further reading on MDM risk level, see this FPM Quick Tips FAQ, this American Medical Association FAQ, or this CPT MDM chart.)

No, the discharge service must take place on the same calendar date that initial newborn care is provided. For example, an infant born on Monday night is first seen by a physician early Tuesday morning and is discharged following a second physician visit on Tuesday evening. Because the admission and discharge both took place on Tuesday's date, code 99463 is appropriate.

Code 16020, “Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)” is appropriate for this service. Note that the code descriptor requires dressing and/or debridement of a burn or burns involving a small percentage of the body's total surface area. If you also provide and document a significant and separately identifiable E/M service (e.g., evaluation for other injuries), report the appropriate E/M code with modifier 25.

Report code Z79.84, “Long term (current) use of oral hypoglycemic drugs” and  Z79.85, "Long-term (current) use of injectable non-insulin antidiabetic drugs"  in addition to the appropriate code(s) describing the patient's diabetes and any manifestations.

(Editor's note: This answer has been corrected with an updated code for injectable drugs.)