What I'm not sure I understand is, what the heck does "poses a threat to life or bodily function" really mean? Surely a fall with ankle pain, non-weightbearing that could potentially be a fracture, represents a threat to bodily function? But then that video thegenius linked to says that would be more of a "low" level problem. I just don't get the verbiage used. The official documentation isn't much better:
"Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity."
So, from everything I've seen, you can basically game most things to a level 4 or 5 chart, and maybe that's the point. I just don't want to be the first one on the wall after trying to defend myself against medicaid fraud for all these high level charts when all I'm trying to do is make sure my group's billing doesn't get undercut.
This is from
The acep faq. I found it very helpful. I agree most things are 4/5
CPT has not published clinical examples for the COPA elements. In addition, the clinical examples for the E/M codes in Appendix C will be deleted from CPT in 2023. The ACEP Coding and Nomenclature Committee has reviewed available CPT guidelines, AMA clarifications published in CPT Assistant, and common practices in the emergency department to offer some guidance when assessing the Complexity of Problems Addressed.
Minimal
- 1 self-limited or minor problem.
- It is improbable that many patients that present to the emergency department clinically fit into this category. CPT stipulates that a problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. Given this description, an illness or injury that warrants a visit to the emergency room seems to exceed what would be considered a self-limited or minor problem. Presentations in this category will most likely be limited to patients who return to the ED for uncomplicated suture removal, dressing changes, or packing removal.
Low
- 2 or more self-limited or minor problems
- See the above description of a self-limited or minor problem.
- 1 stable chronic illness and
- 1 stable, acute illness
- The CPT definition of “Stable” makes it doubtful that patients presenting to the department fit into these categories.
"Stable" for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.
A patient who presents with an illness or injury to be evaluated by the emergency physician does not fit this definition of stable. Additionally, CPT indicates these are “A problem that is new or recent for which treatment has been initiated…” which is unusual in the emergency department setting.
- Acute, uncomplicated illness or injury
- ED presentations in this category will be limited to localized complaints that do not include additional signs or symptoms.
- Uncomplicated injuries will be minor traumatic injuries that are appropriately evaluated without x-rays (e.g., extremity injuries with limited pain, swelling, or bruising) and can usually be managed with over-the-counter medications. Injuries that require prescription medications for more aggressive pain management or other prescription medications (e.g., antibiotics due to infection risk) are typically more consistent with an acute complicated injury.
- Uncomplicated illnesses are minor illnesses with no associated systemic symptoms and can be evaluated without testing or imaging (e.g., isolated URI symptoms). Most of these patients can be reasonably treated with over-the-counter medications. Illnesses that have developed associated signs or symptoms, or require testing or imaging, or necessitate treatment with prescription strength medications have progressed beyond an uncomplicated illness.
- 1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care
For physicians and coders working in the emergency department, a patient that requires hospitalization seems out of place in the Low COPA category. AMA CPT personnel have said that this bullet was added to provide a mechanism to score Low MDM as required for the inpatient hospital/observation E/M codes. This bullet should not be used when calculating the MDM for patients in the emergency department.
Moderate
- 2 or more stable chronic illnesses.
- See the above explanation of stable chronic illness.
- 1 acute complicated injury
- As indicated by the CPT definition, these are injuries that require an evaluation of organ systems or body areas beyond just the injury site (e.g., musculoskeletal injuries where an assessment of distal neurovascular function is indicated).
- A patient’s mechanism of injury can also be an indication of an acute complicated injury. ED presentations prompted by a fall, MVA, fight, bicycle accident, or any other accident require the physician/QHP to evaluate multiple organ systems or body areas to identify or rule out injuries.
- Accidents and/or injuries that necessitate diagnostic imaging to rule out significant clinical conditions such as fracture, dislocation, or foreign bodies are indicative of a potentially extensive injury with multiple treatment options and risk of morbidity.
- 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment.
- Stylistically, this element is listed as above in the MDM table, but it should be interpreted as:
- chronic illnesses with exacerbation, OR
- chronic illnesses with progression, OR
- chronic illnesses with side effects of treatment.
- 1 undiagnosed new problem with uncertain prognosis.
- 1 acute illness with systemic symptoms.
- There are many presenting problems, chief complaints, and associated signs and symptoms that could fit into these three categories.
In response to a reader’s question, CPT Assistant indicated that abdominal pain would likely represent “at least” Moderate COPA. This could be a patient with chronic abdominal pain, so the presentation would be considered a chronic illness with exacerbation. It may be a patient with no history of abdominal pain that would be an undiagnosed new problem with uncertain prognosis. Or it might present as abdominal pain with vomiting and diarrhea, so it would score as an acute illness with systemic symptoms
.
This concept can be applied to many evaluations for patient complaints that should be considered at
leastModerate COPA. The following are some examples, but this
is not an all-inclusive list:
| Abdominal pain | Psychiatric complaints |
| Back pain | Shortness of breath |
| Chest pain | Systemic rash |
| Diarrhea | Vomiting |
| Dizziness | Weakness |
| Headache, Neck pain | Syncope |
It is important to recognize that all of these presentations exist within a clinical spectrum of severity. At the moderate level, diagnostic evaluations for these would likely involve simple testing, such as plain x-rays or basic lab tests.
- Systemic symptoms may involve a single system or more than one system. Presentations representing two or more systems seem to exceed a single acute uncomplicated illness or injury, suggesting at least a moderate COPA. CPT states, “Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.”
- Fever is generally considered to likely represent a systemic response to an illness. CPT states that fever associated with a minor illness that may be treated to alleviate symptoms is more typical of an uncomplicated illness. For example, an otherwise healthy patient with a fever solely associated with uncomplicated viral URI symptoms is a less concerning clinical process. However, fever or body aches not associated with a minor illness or associated with illnesses requiring diagnostic testing or prescription drug management may represent a broader complexity of problem being addressed or treated.
- Regardless of final diagnosis, accidents and/or injuries that necessitate diagnostic imaging to identify or rule out a clinical condition such as a fracture, a dislocation, or a foreign body are indicative of a potentially extensive injury with multiple treatment options and risk of morbidity and consistent with an undiagnosed new problem with uncertain prognosis.
- The physician/QHP ordering and/or reviewing extensive labs and/or complex imaging and/or consulting with a specialist indicates an investigation to evaluate for broader concerns with more complex clinical considerations. This would suggest that the encounter has exceeded what would reasonably be considered moderate COPA.
High
- 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
- Stylistically, this element is listed as above in the MDM table, but it should be interpreted as:
- chronic illnesses with severe exacerbation, OR
- chronic illnesses with severe progression, OR
- chronic illnesses with severe side effects of treatment.
- 1 acute or chronic illness or injury that poses a threat to life or bodily function
- Presenting problems in these High COPA categories are high-risk presentations where the physician/QHP is evaluating or ruling out a condition with a significant risk of morbidity or one that poses a threat to life or bodily function. These are patients with symptoms that potentially represent a highly morbid condition and therefore support high MDM even when the ultimate diagnosis is not highly morbid.
The final diagnosis for a condition, in and of itself, does not determine the complexity of the MDM. The presenting problem, or diagnostic evaluation, or treatment or management, or differential diagnoses, may indicate that an extensive evaluation is required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.
The following high COPA examples may be demonstrated by the totality of the medical record as demonstrated implicitly by the presenting problem, or diagnostic evaluation, or treatment or management, or differential diagnoses, or overall medical decision making, as demonstrated in the entire record.
This is not an all-inclusive list; high COPA should be considered for evaluations of patients with presentations potentially consistent with, but not limited to:
| Active labor | Missed/incomplete abortion |
| Ectopic pregnancy | Ocular emergencies |
| Acute intra-abdominal infection or inflammatory process | Ovarian torsion |
| Behavioral health decompensation | Pulmonary embolism |
| Cardiac arrhythmia | Seizure |
| Cardiac ischemia | Sepsis |
| Congestive heart failure | Sickle cell crisis |
| Croup or asthma requiring significant treatment | Significant blood loss |
| CVA, acute neurological change | Significant complications of pregnancy |
| DKA or other significant complications of diabetes | Significant eye injury |
| Endocrine emergencies | Significant fractures or dislocations |
| Epiglottitis | Significant infection |
| Exacerbation of CHF | Significant metabolic disturbance |
| Exacerbation of COPD | Significant penetrating trauma |
| Gastrointestinal obstruction | Significant vascular disruption, aneurysm, or injury |
| Hypertensive crisis | Solid organ injury |
| Intracranial hemorrhage | Testicular torsion |
| Intra-thoracic or intra-abdominal injury due to blunt trauma | Toxic ingestion |
| Kidney stone with potential complications | |
It is not necessary that these conditions be listed as the final diagnosis. An extensive evaluation to identify or rule out these or any other condition that represents a potential threat to life or bodily function is an indication of High COPA and should be included in this category when the evaluation or treatment is consistent with this degree of potential severity.
ernotes.net
