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: My coders keep telling me that my exam of a patient’s head, neck, and back or chest wall just isn’t good enough for a Level 5. Why?
Answer: Medicare documentation guidelines make a distinction between body areas and organ systems, and that distinction is what distinguishes a Level 5 exam. The most important thing to remember when coding examinations is that a Level 5 (99285) exam requires that eight or more organ systems be examined and documented. For lower levels of service (Levels 1–4, 99281–99284), it doesn’t matter whether you use body areas or organ systems or mix and match them.
For a Level 1–4 (99281–99284) examination, it’s acceptable to mix and match the following body areas with organ systems:
- Head, including the face
- Chest, including breasts and axillae
- Genitalia, groin, buttocks
- Back, including spine
- Each extremity
For a Level 5 (99285) examination, however, you must use eight or more of the following organ systems:
- Constitutional (eg, vital signs, general appearance)
- Ears, nose, mouth, and throat
For more information about documentation requirements, please see ACEP FAQs.
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.
Dr. Lempert is vice president and medical director, health care financial services, at TeamHealth, based in Knoxville, Tennessee.