Praxis II: Professional School Counselor

Correct: According to the 2023 CPT E/M guidelines, the ‘Amount and/or Complexity of Data to be Reviewed and Analyzed’ element of Medical Decision Making includes a specific category for the ‘Discussion of management or test interpretation with external physician or other qualified health care professional.’ This allows the physician to receive credit for the cognitive labor involved in consulting with a specialist to manage the patient’s care.

Incorrect: The Risk of Complications and/or Morbidity or Mortality refers to the risk associated with the patient’s condition or the treatment options selected, not the act of consultation. The Number and Complexity of Problems Addressed refers to the severity and nature of the presenting illness or injury. Total Time is not used as a basis for selecting E/M levels in the Emergency Department (codes 99281-99285), as these services are not time-based.

Takeaway: In the Emergency Department, a discussion with an external physician regarding patient management is credited under the Data element of Medical Decision Making.

Correct: According to the ICD-10-CM Official Guidelines for Coding and Reporting for outpatient services (including the ED), if a definitive diagnosis is not established at the conclusion of the encounter, the coder should report the signs, symptoms, abnormal test results, or other reasons for the visit. While specific pandemic-related codes (such as U07.1) may have unique instructions, the general rule prohibits coding ‘suspected,’ ‘probable,’ or ‘rule out’ conditions in the outpatient setting.

Incorrect: Assigning codes for suspected conditions in an outpatient setting is a violation of ICD-10-CM guidelines, which require coding to the highest level of certainty (symptoms). Holding all claims for 30 days is an inefficient administrative burden that does not address the underlying coding accuracy requirement. Applying a standard modifier to bypass diagnosis coding is not a recognized coding practice and would lead to claim rejections or compliance audits.

Takeaway: In the Emergency Department, coders must report signs and symptoms rather than suspected diagnoses unless specific official guidelines for a pandemic pathogen provide an exception.

Correct: Performing a retrospective review and returning overpayments is the only ethically sound action. According to HIM ethics and global health standards, coding must be based strictly on official guidelines and the actual clinical documentation provided by the physician. Assigning codes to meet external financial or research thresholds (upcoding) is a violation of professional integrity and legal standards. Correcting the data ensures the accuracy of global health surveillance and maintains the facility’s compliance with healthcare regulations.

Incorrect: Revising the manual to use non-standard definitions is a violation of ICD-10-CM coding conventions and misrepresents the patient’s clinical state. Forcing physicians to use specific keywords to justify a code is an unethical practice known as leading the provider, which compromises the integrity of the medical record. Limiting the audit scope to only flagged cases is a failure of internal controls and does not address the systemic ethical breach or the requirement for accurate health data reporting.

Takeaway: Ethical coding in the ED requires that diagnosis and procedure codes are derived strictly from provider documentation, independent of external financial incentives or research grant requirements.

Correct: Establishing a concurrent query program is a proactive HIM strategy that ensures documentation accurately reflects the Medical Decision Making (MDM) performed. Under current E/M guidelines, the ‘Amount and/or Complexity of Data to be Reviewed and Analyzed’ is a key component of MDM. By querying physicians in real-time about independent interpretations of tests or discussions with external sources, HIM ensures the code assigned (such as 99284 or 99285) is supported by the medical record before the claim is finalized, maintaining both compliance and revenue integrity.

Incorrect: Automatically assigning codes based on patient disposition or specific diagnostic tests is considered upcoding and fails to meet the requirement that the physician’s documentation must support the specific level of MDM. Relying on nursing triage scores is inappropriate because the physician’s E/M level must be based on the physician’s own documented work and decision-making. A retrospective-only model is reactive rather than proactive and increases the risk of compliance audits and financial instability due to frequent rebilling and potential overpayments.

Takeaway: A compliant proactive HIM strategy involves real-time physician queries to ensure that all elements of Medical Decision Making, especially data review and risk, are clearly documented.

Correct: Under HIPAA, for a record to be considered de-identified for use in public or semi-public forums like HIM learning platforms, it must either follow the Safe Harbor method (removing 18 specific identifiers, including all elements of dates more specific than a year) or the Expert Determination method. Leaving a specific date of service combined with a rare diagnosis creates a high risk of re-identification, which violates the Safe Harbor requirements.

Incorrect: Removing only the name, address, and SSN is insufficient under the Safe Harbor method, as it specifically requires the removal of all geographic subdivisions smaller than a state and all elements of dates. The TPO exception allows for internal operations but does not generally permit posting PHI to external or public-facing learning platforms. A BAA is an agreement between a covered entity and a service provider, not a mechanism to allow sharing PHI with a general public audience or unverified platform users.

Takeaway: Proper de-identification of ED records for educational platforms requires the removal of all 18 HIPAA identifiers or an expert’s assessment of re-identification risk.

Correct: According to the 2023 CPT E/M guidelines, Social Determinants of Health (SDoH) are specifically recognized under the ‘Risk’ element of Medical Decision Making. When a patient’s management is limited by social factors (such as housing instability preventing the use of certain medications), it qualifies as a ‘Moderate’ level of risk. This aligns with HIM diversity and inclusion initiatives by ensuring that the complexity of treating vulnerable populations is accurately reflected in the coding and reimbursement process.

Incorrect: Option B is incorrect because CPT guidelines explicitly include SDoH as a factor in MDM risk. Option C is incorrect because SDoH factors do not automatically trigger a Level 5 (99285) visit; the level is determined by the overall complexity of all three MDM components, and SDoH typically maps to moderate risk. Option D is incorrect because Emergency Department E/M codes (99281-99285) are not time-based codes; they are assigned based on the level of MDM performed.

Takeaway: Social Determinants of Health (SDoH) that limit patient management are recognized as a moderate risk factor in the Medical Decision Making (MDM) framework for ED E/M coding.

Correct: According to the ICD-10-CM Official Guidelines for Coding and Reporting (Section I.B.14), codes for Social Determinants of Health (Z55-Z65) are an exception to the general rule that only the patient’s provider can document diagnoses. These codes may be assigned based on medical record documentation from any clinician involved in the patient’s care, such as social workers, nurses, or case managers, because the information represents social status rather than a clinical medical diagnosis.

Incorrect: Requiring the attending physician to restate social factors documented by other clinical staff is unnecessary under official guidelines and contributes to the under-reporting of health disparities. Restricting SDOH codes to only those that are the primary reason for the visit ignores the guideline that these codes are intended to be reported as secondary diagnoses to provide context for the patient’s health status. Using HCPCS modifiers is incorrect because SDOH are specifically classified as ICD-10-CM diagnosis codes in the Z-code range.

Takeaway: SDOH codes (Z55-Z65) can be assigned based on documentation from any healthcare team member, facilitating more accurate tracking of health disparities.

Correct: According to CMS and the OPPS (Outpatient Prospective Payment System) guidelines, hospitals are permitted to develop their own internal systems for mapping ED facility levels. These systems must reasonably relate the intensity of hospital resources (nursing time, supplies, equipment) to the different levels of effort represented by the CPT codes. As long as the system is consistently applied and documented, the facility level does not need to match the professional level, as they measure different types of resource consumption.

Incorrect: Matching the professional level is incorrect because professional coding measures physician work and medical decision-making, while facility coding measures hospital resource use. Using the 1995 or 1997 guidelines is incorrect because those guidelines were designed for professional services, not facility resource tracking. Relying exclusively on triage acuity is incorrect because it only captures the patient’s status at arrival and fails to account for the actual resources consumed during the entire course of the emergency department visit.

Takeaway: Facility E/M levels in the ED are based on hospital resource consumption through a consistently applied internal methodology, which may legitimately differ from professional levels based on physician work.

Correct: In the context of Emergency Department coding, particularly under current E/M guidelines, Medical Decision Making (MDM) is the primary driver for selecting the level of service. While HIM environmental stewardship encourages the use of EHR efficiencies, documentation must be encounter-specific. If a coder identifies cloned documentation that does not reflect the patient’s current state but the MDM suggests a higher complexity, the coder must focus on the unique MDM elements and query the provider to ensure the documentation accurately reflects the services provided during that specific encounter.

Incorrect: Assigning a level based on cloned data is incorrect because it may not reflect the actual work performed or the patient’s current condition, leading to compliance risks. Defaulting to the lowest level (99281) is an inappropriate application of coding rules and results in under-coding. Relying solely on nursing notes or the final diagnosis ignores the physician’s documented MDM and professional responsibility, which are central to determining the correct E/M level.

Takeaway: Documentation integrity in an EHR environment requires that each encounter note uniquely reflects the patient’s current status and the physician’s specific medical decision-making for that visit.