Outpatient Facility Coding Alert - 2013 Issue 2
Reader Question: Don't Say Nope to the NOPP, Nature of the Presenting Problem Must be Considered
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Article Overview
This reader Q&A discusses emergency department evaluation and management coding, with emphasis on how the nature of the presenting problem relates to medical necessity and documented history, exam, and medical decision-making. It is aimed at coders and auditors who work with CPT-based ED E/M selection and need to understand why documentation volume alone may not determine the appropriate level of service.
Why This Topic Matters
It helps coding professionals interpret ED E/M documentation in a way that aligns with medical necessity and payer expectations, reducing the risk of inaccurate code selection during audits.
Article Sections
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Question
A reader asks how the presenting problem should factor into selecting an emergency department level of service when the chart appears to support higher documentation elements.
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Answer
The response explains the broader relationship between documentation, medical necessity, and emergency department E/M selection, with discussion of CPT and CMS guidance.
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Nature of Presenting Problem (NOPP) and ED E/M Levels
This section outlines the emergency department E/M service levels and the general severity categories associated with them.
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CMS Medical Necessity Guidance
The article summarizes payer guidance stating that medical necessity is central to payment and should not be driven by documentation volume alone.
What You Will Learn
- How the nature of the presenting problem relates to emergency department E/M selection
- Why medical necessity is important in evaluation and management coding
- How CPT and CMS guidance influence ED coding review
- Why documentation elements alone may not determine the final service level
Who Should Read This
- Medical coders
- Coding auditors
- Emergency department billers
- Compliance staff
- Physician documentation reviewers
Codes Discussed
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