ED Coding and Reimbursement Alert

How the “Acuity Caveat” could be sabotaging your documentation.

As an ED coder, you’re facing heightened scrutiny from insurance company auditors who’re scouring E/M claims for documentation gaps in history of present illness. If your physicians adequately noteanatomic site details when patients present with illness and understand how to apply the acuity caveat, you’ll circumvent denials and down-coded claims.

The challenge: Our industry has done a great job educating our physicians on the documentation requirements for the emergency department E/M codes, says Todd Thomas, CPC, CCS-P, President of the ERcoder, Inc. in Edmond OK. This has made it more difficult for auditors to find justifiable reasons to down code our claims.

“As a result, some auditors are being rather restrictive in their interpretation of some of the E/M components and the documentation in the ED chart. This is frustrating for emergency physicians trying to provide good patient care and professional coders working on their behalf to obtain accurate reimbursement for the services provided in the emergency department.” Thomas explains.

The good news: These restrictive interpretations can often be overturned on appeal. “If I can argue our case to the medical director or somebody with a clinical background employing a common sense approach, logic and sound coding theory can usually sway the decision in our favor. Many of these arguments can be avoided in the first place with better documentation”, says Thomas.

Specify Location for Illnesses

Location is an easy HPI element to document for patients that present with an injury, but can be a little harder to define for patients that present with an illness.

Some illness presentations seem to have a location component built into the complaint, but auditors would disagree. Some auditors have been reluctant to count the location component for chief complaints like chest pain, headache and abdominal pain without further elaboration as to the specific location. Their argument is that chest pain is the complaint and the location of the complaint needs to be documented as left, right, substernal, etc.

Real life example: “I’ve fought this issue with a couple of payers in recent years”, says Thomas. “One auditor dug their heels in and refused to concede the point. When the claims were appealed to the next level, the physician auditor agreed with the initial reviewer, stating that his concern was more about quality care and clear documentation and not so much about the issue of three HPI elements versus four HPI elements.”

The physician auditor cited the example of a patient who presents to the ED with abdominal pain, Thomas relates. In his opinion, the physician cannot perform a clinically appropriate history for an abdominal pain presentation without asking where the abdominal pain is located: left upper, right lower, flank, etc.” All have their own list of potential causes, and the physician has to know where the pain is located to develop a list of differential diagnoses, determine the appropriate diagnostic tests and begin considering therapeutic interventions,” says Thomas. If the physician did not inquire about a specific location, that’s poor clinical judgment or if he did and did not document the location, that’s poor documentation, and neither behavior should be rewarded, he adds.

Hard way vs. easy way: You can certainly be prepared to argue the point that these types of presenting problems include a location element simply by their nature, but the argument can be avoided altogether by simply training emergency physicians to document specific location statements, says Thomas.

Don’t Take Liberties With Implied Acuity Caveat

The CMS Documentation Guidelines include two clauses that allow for incomplete documentation for an E/M service when the patient is too ill to allow the normal H&P that would be indicated. These are commonly referred to as the Acuity Caveat and the History Caveat and are invoked in those scenarios where the patient’s condition prevents the ED physician from being able to perform a comprehensive history and/or exam, Thomas explains.

The Acuity Caveat means that the provider doesn’t necessarily have to document a comprehensive history, but it does not fully excuse them from documenting the clinical encounter as thoroughly as possible.

Review the guidelines: In the CPT^® description of 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity), we are instructed to meet the documentation requirements “within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status”.

CMS version: There is similar guidance in the CMS E/M documentation guidelines, which state” If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.”

The inability to obtain a comprehensive history or perform a comprehensive exam is a clinical decision based on the judgment of the emergency physician at the bedside, says Thomas. In those instances where the urgency of the patient’s condition prevented the emergency physician from performing a comprehensive history, it should be reflected in the emergency department record.

Doctor’s responsibility: The coding staff should not be expected to review a chart with limited documentation and make the decision that the documentation shortfalls are due to the severity of the patient’s presentation. Audit experience has shown that without the emergency physician documenting that the history was limited or unavailable due to the patient’s condition, auditors are likely to downcode the chart for insufficient history, Thomas warns.

Coding example: Thomas offers this HPI from a chart that was appealed after the payer downcoded the encounter due to insufficient history. “Patient is a 28YF brought in by air. Patient was found on the roadside with multiple lacerations and abrasions. She was intubated at the scene for altered mental status and is unresponsive on arrival. It is not known if she was involved in a MVC, fell or thrown from vehicle, or was a pedestrian hit by a car.” This encounter was coded and billed as a 99285 and downcoded by the payer to 99283 for insufficient history.

Don’t Be Afraid to Appeal to A Higher Authority

When I contacted the payer about the down code, I was told by the auditor that they would not allow 99285 because the physician had not documented a comprehensive history, says Thomas. After several minutes of back and forth with the auditor, I asked to speak to her supervisor.

The supervisor had a background as a registered nurse and agreed that it was unrealistic to expect the physician to perform a comprehensive history on an unresponsive, intubated patient. She reversed the initial decision and agreed to pay the claim as a 99285. However, she went on to explain that her auditors cannot be expected to know the difference between a chart that has limited documentation due to the severity of the patient’s presentation versus a chart with limited documentation simply because the physician failed to document a comprehensive history.

So while the emergency physician’s group did prevail in this instance, this argument could have easily been avoided if the emergency physician’s documentation had invoked the Acuity Caveat, says Thomas.

Document Why You Are Invoking the Caveat

At a minimum the emergency physician should document the reason that the history was not obtained, i.e. “Hx unobtainable due to dementia” or “Severity of patient’s injury precludes obtaining a full history”. Best practice would be to also document the source of any documented history and/or that no other sources of history were available, warns Thomas.

Simple fix: In the example case, the physician could have avoided the down code and appeals process by documenting “Unresponsive and intubated patient unable to provide any additional history. No family members or past medical records available.” With this simple statement in the emergency record, he could have created a bulletproof chart that would have stood up to the audit process, Thomas adds.