Q4 Urgent Caring- Coding Corner: Addressing Common Coding Pitfalls

Brad Laymon PA-C, CPC, CEMC
Section Editor, Coding Corner

In this coding education section, we will address nine areas of common coding pitfalls for clinicians:

1)     Abnormal vital signs– Generally, abnormal vital signs should be added as a diagnosis if not part of a primary diagnosis. For example, unexplained tachycardia should be added as a diagnosis. Tachycardia in the setting of Influenza is not necessary.  Any patient whose BP is elevated in the center should have it added as a diagnosis. If they have a a history of HTN, then you have met the criteria for a chronic illness with exacerbation. If they do not have a history of HTN, elevated BP could be added as a diagnosis with a plan for dealing with the elevated BP.

2)     Independent historian– An independent historian can be a parent, guardian, surrogate, spouse, witness (to name a few) who provides all or part of the history because the patient is unable to provide a complete or reliable history due to the patient’s age, dementia, psychosis, etc. or because a confirmatory history is judged to be necessary. The independent historian does not need to be obtained in person. Translator services do not count and most importantly, the independent historian needs to be documented.

3)     Prescription drug management– Prescription drug management is met when the provider discusses, starts, continues, discontinues, or adjusts a prescription medication. Documentation of the drug, strength, and dosage should be included in the note. There must be documentation of one of the following: 

  1. a prescription drug that the provider is evaluating the appropriateness for the patient and/or continuing to prescribe for the patient
  2. documentation on the prescription drug(s) that are being considered and the reason why they are being considered 
  3. documentation of a decision to initiate a new prescription drug
  4. documentation of a provider’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition
  1. the patient’s condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug

4)     Tests considered but not ordered– If you recommend POC tests or other labs but the patient refuses, if you document this conversation, it will count towards the complexity of data. Consider this; you see a 66-year-old male patient with a complaint of fever up to 102.4, body aches, cough, loss of appetite, nausea, and fatigue. You recommend POC tests for influenza and COVID but the patient refuses. Documentation of this would count as if you had performed these tests. Frequently, with appropriate documentation, this could elevate a level 3 complexity of data to an appropriate code of level 4 complexity of data.  

5)     Comorbid conditions– If the patient has a comorbid condition which could increase the risk of complications and/or management of the patient, these conditions should be added as a diagnosis and a brief treatment plan be included in the MDM. For example, a diabetic patient with a foot wound can increase the risk of patient management. Adding diabetes as a secondary diagnosis and a brief treatment plan, “patient will continue metformin 500 mg BID, check blood glucose level daily, maintain a strict diabetic diet, and follow up with PCP,” is sufficient.

6)     Systemic symptoms– Systemic symptoms would include SIRS criteria, nausea and vomiting not in the setting of GE, moderate-severe fatigue, confusion, dizziness, rash which is not dermatologic in nature, body aches, loss of appetite, to name a few. To meet the criteria for “acute illness with systemic symptoms”, the guidelines state, “systemic symptoms may not be general but may be single system”. Most influenza, pneumonia, pyelonephritis, and COVID patients would meet this criterion.

7)     Tobacco counseling– Tobacco counseling is often overlooked. If you have a conversation with the patient regarding smoking cessation, we can add a CPT code for this counseling. The counseling must be at least three minutes long to meet the criteria. The CPT code for 3-10 minutes is 99406 and for >10 minutes, the code is 99407.

8)     ED transfers– Most patients who need ED transfer via EMS will be level 5 patients. Documentation of the patient’s condition and any abnormal vital signs or an acutely ill patient will warrant a level 5 code. For the patient who is stable with normal vital signs, documentation of a differential diagnosis would be helpful when choosing the correct level of service. For example, the chest pain patient with a normal EKG and normal vital signs who is not acutely ill, documenting a differential diagnosis to include possible cardiac event or PE, will usually be a level 5 visit.

9)     Undiagnosed new problem with uncertain prognosis– a patient presenting with symptoms such as persistent fatigue, unexplained weight loss, and enlarged lymph nodes would fit into this category. Despite various tests and investigations, the exact cause of these symptoms remains unknown. The uncertainty surrounding the diagnosis and prognosis can pose a challenge in providing the patient with a clear treatment plan and long-term outlook. Patients with chest pain, abdominal pain, or headache will fit nicely in this category IF they are not acutely ill and require ED evaluation.