Objective Criteria for Emergency Medicine E/M Code Choice

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When selecting final E/M code choice, to reach the High Level MDM, a coder must have:

High Risk plus Table A at 4 points

High Risk plus Table B at 4 or > points

Table A at 4 points plus Table B at 4 or > points

Any of the above.

Which of the following is an example of management options that would generally start as E/M Level 99282:

A recheck visit with a focused exam

No prescription on discharge

Order and administration of one nebulizer

Referral to the ED for an IM tetanus

Low moderate risk is a moderate complexity case that would generally start at which of the following E/M levels:

E/M Level 99282

E/M Level 99281

E/M Level 99284

E/M Level 99283

Which of the following is an example of a Low-Moderate presenting problem:

A patient presents with several uncomplicated insect bites.

A patient presents for removal of sutures from a well-healed, uncomplicated laceration

A pregnant patient who presents with abdominal pain

A patient is sent from his PCP’s office to receive a tetanus toxoid immunization

Which of the following is an example of a Low-Moderate presenting problem:

Vaginal discharge w/out abdominal pain

Vaginal discharge w/ abdominal pain

Abdominal pain w/ a pelvic exam

Abdominal cramping w/ a rectal exam

Which of the following objective criteria is an example of a High-Moderate management option for shortness of breath:

Order and interpretation of two EKGs

Order and administration of one nebulizer medication alone (usually Albuterol)

Order and evaluation of a CMP and an x-ray

Order and administration of two IV Solu Medrol and Decadron

Which of the following objective criteria is an example of a High-Moderate exam, evaluation, or consultation:

Pelvic exam

Any medical or surgical consultation.

Psych evaluation by a psych professional

Psych evaluation by an ED provider with no request for a professional psych evaluation

Which of the following is an example of a Low-Moderate objective criteria for medication or IV fluids:

Two to three IM/SQ non-controlled medications

One IM/SQ controlled medication

Any prescription (Rx) on discharge

One IM/SQ non-controlled medication with an ancillary study, a lab, or an x-ray

Which of the following is an objective example of a High-Moderate presenting problem:

Trauma patient who presents to the ED via EMS. The patient is restrained and the patient’s cervical spine is immobilized.

Uterine monitoring in Labor & Delivery of a 16-weeks-pregnant patient

Non-trauma patient who presents via EMS

A patient with nausea and vomiting who receives no therapy in the ED

Which of the following is an objective example of High-Moderate ancillary studies:

One to three lab studies

Four or more lab studies or three lab studies and one x-ray series

One isolated x-ray series

Two labs and one x-ray series

Which of the following is an objective example of a High risk presenting problem:

A 30-week pregnant female requiring post-traumatic uterine monitoring in Labor & Delivery

A patient on whom CPR is performed throughout the duration of the visit necessitating use of the acuity caveat

Urinary retention requiring insertion of a Foley catheter

Coordination of admission for a patient who was transported from another facility

True or False: Administration of medications that fall in the High risk category guarantees a Level 5 (99285) case.

True

False

Which of the following is an objective example of a High risk patient disposition:

Most patients who are placed in observation

Most admitted and transferred patients

Rape cases, and child or elder abuse cases

All of the above.

Which of the following is an objective example of High Risk ancillary studies:

Four or more ancillary studies plus IV fluids and any parenteral medication (IV, IM or subQ)

Two to three lab studies

One isolated x-ray series

Two labs and one x-ray series

Which of the following is an example of a High Risk abdominal pain work-up:

Order of an Ultrasound

Order of a UA and Zofran

Order of an Ultrasound followed by a CT scan of the abdomen and pelvis

A rectal exam with order of a UA, a UCG and IV Fluids

Objective Criteria for Emergency Medicine E/M Code Choice – Part 2