ED Coding and Reimbursement Alert

Hint:  Why you should ax conditions irrelivant to treatment

Diabetes, asthma and migraine headaches can all bring a patient into the emergency department--or they can just be the sideshow to the presenting complaint. Check out these three tips to figure out when these conditions matter to your code choice.

1. Select Codes Based on Medical Relevance

You should only report chronic conditions when they-re relevant to the service provided, says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Lansdale, Pa.

Example 1: A patient with high cholesterol (272.0, Pure hypercholesterolemia) arrives with a closed fracture of the collarbone (810.x, Fracture of clavicle). He isn't now on any medication. The physician treats the fracture without manipulation (23500, Closed treatment of clavicular fracture; without manipulation). If the doctor confirms that the cholesterol level wasn't medically relevant, only code the broken collarbone.

Avoid This Pitfall

If the physician reports high cholesterol along with the fracture, don't immediately discount the cholesterol diagnosis. Check with the doctor to see if the cholesterol affected his treatment options. For instance, he may have had to consider it when prescribing medication.

Example 2: A diabetic patient presents with a closed fracture of the collarbone. The diabetes may put the patient at increased risk of infection and affect the physician's ability to choose steroids as an anti-inflammatory. In this case the chronic condition--diabetes (250.x, Diabetes mellitus)--does affect the physician's treatment options, so you should code for it.

Tip: If your physician uses a superbill, ask him to code only for those diagnoses that are medically relevant, whether it's because they affect care or because the patient has two conditions with similar symptoms and the physician must determine which is causing the current problem.

2. Know the E/M Documentation Guidelines

One place to look for documentation of a clinically relevant chronic condition is in the history of present illness (HPI) section of the E/M report.

Example: Your physician specifically questions the patient about her diabetes (250.xx), pulmonary edema (514, Pulmonary congestion and hypostasis) and high blood pressure (401.x, Essential hypertension)--all of which are chronic, according to the documentation--as part of his history-taking.

Note: Check your payer guidelines. While the documentation guidelines allow the physician to evaluate and document the status of chronic conditions to satisfy the HPI requirements, this will not often support medical necessity for an ED visit, says Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI, an ED coding and billing company in Stoneham, Mass.

3. Separate Condition From Symptom

Remember that the same complaint may be a chronic condition in one patient and a symptom of a condition in another--it's all in the documentation, says Susan Hvizdash, CPC, an auditor for the University of Pittsburgh Physicians, Department of Surgery in Pennsylvania.

Headache example 2: A patient arrives complaining of a terrible headache that the physician concludes is the result of acute sinusitis (461.x, Acute sinusitis). The headache in this case is a symptom of an acute condition.

Bottom line: Accurate documentation of chronic conditions is important because it allows you to choose the most specific diagnosis code, Hvizdash says. Choosing the correct code for your claim supports the medical necessity of the procedure you report, making it less likely your payer will ask to review your documentation, she adds.

Next time a report lands on your desk and reveals an ailment that could be a chronic condition, don't automatically code for it. Be sure the problem is relevant to the treatment and that it truly is a condition rather than a symptom of something else.