Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transition. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze.

Question: I know there are five levels of service for emergency department E/M codes, but what really determines the level?

Answer: In addition to the nature of the complaint, the complexity of your medical decision making (MDM) is paramount. How extensive was your differential diagnosis? After you performed the history and physical examination, did you need to do any additional work-up? The results of lab tests and your review or interpretation of ECGs and X-rays should all be documented. Be sure to document any bedside ultrasounds and any discussions you have with the radiologist about the results of CT scans. All of these add to the complexity of the data reviewed. Did you need to consult a specialist? This would also add to the complexity of the care delivered. If the patient was treated with IV fluids or received any medications, documenting the treatment and the patient’s response helps show the risk of complications. Of course, your documentation of the history and physical examination needs to be complete and accurate. More information about getting credit for additional work-up can be found at the ACEP FAQ page under the Medical Decision Making and the Marshfield Clinic Scoring Tool FAQ.

Brought to you by the ACEP Coding and Nomenclature Committee.

Dr. Lemanski is associate professor of emergency medicine at Baystate Medical Center/Tufts University School of Medicine in Springfield, Massachusetts, and chair of the ACEP Coding and Nomenclature Committee.