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Question: A patient with benign prostatic hyperplasia (BPH) without lower urinary tract symptoms presents to emergency department (ED) for a prescription refill, as they don’t have a primary care physician (PCP). The patient presents every month for the same refill of their BPH medication. These visits involve minimal Amount and/or Complexity of Data to Be Reviewed and Analyzed. The patient is not on any other medication. The patient has no other significant past medical history (PMH) and no other chronic conditions; other than the BPH medication, they are not on any other medication.

What ED evaluation and management (E/M) code should I report? I was thinking that the medical decision making (MDM) was minimal, which would mean a level 1 or level 2 E/M.

Tennessee Subscriber

Answer: Actually, the MDM is low, so you would report 99283 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making) for this encounter. Just make sure you include the ICD-10-CM code N40.0 (Benign prostatic hyperplasia without lower urinary tract symptoms) to represent the patient’s BPH.

Explanation: The code choice comes down to MDM level. Although the Amount and/or Complexity of Data column is minimal, BPH is a chronic condition, so that means the physician managed one stable chronic illness (low MDM). The physician also performed prescription drug management, which is moderate in the Risk of Complications and/or Morbidity or Mortality of Patient Management.

Since you have one low MDM element and one moderate, the MDM is considered low and 99283 is your code choice.

Chris Boucher, MS, CPC, Senior Development Editor, ÂþÏã¸ó