ED Coding and Reimbursement Alert

ED coders must rely heavily on the documentation recorded by the physician and learn how to fairly weigh elements of the physical exam (PE), history and medical decision-making (MDM) to select the correct E/M visit code (99281-99285).

When determining the service level, coders generally begin by reviewing the history (including the history of the present illness or HPI; review of systems or ROS; and the past medical, family and social history, or PFSH) and the PE (including the number of body areas or organ systems examined). Because these are quantified relatively easily, these two key components cause few problems.
 
MDM presents a different sort of challenge, however, says Peter Sawchuk, MD, president of Eidos Healthcare Resources in Green Pond, N.J., who describes MDM as a nebulous area of E/M coding. "There is very little in the way of authoritative direction given. It's a hodge-podge essentially a 'look-yourself-in-the-mirror' issue. Physicians and coders must find ways to ensure they are uniformly applying standards with which they are comfortable."
 
Kathy Pride, CPC, CCS-P, health information management applications specialist with QuadraMed, a national heathcare information technology and consulting firm based in San Rafael, Calif., concurs. "When it comes to E/M coding, medical decision-making is without a doubt the most confusing, the most subjective area," she says.

To help you achieve supportable standards for deter-mining MDM, Sawchuk recommends two approaches:
 
1. Each ED practice needs to review the processes it uses to determine the complexity of MDM and formalize its approach. "It must be consistent, and it must be reasonable," he says. "It would not be appropriate to apply one standard to one group of patients and another standard to a second group unless, of course, the specific payers in question enforce different policies." The guidelines should be included in the practice's compliance plan, which should outline the rationale behind them, and then should be consistently followed. When establishing guidelines for MDM, Sawchuk adds, coding professionals should consult with local Medicare carriers and other payers to ensure their policies don't contradict insurers' rules.
 
2. ED coders should find out whether local Medicare carriers have adopted the Marshfield Clinic Audit Tool and, if so, use it to help develop their practice's MDM guidelines. "When it introduced the 1995 documentation guidelines (DGs), Medicare circulated this audit tool to its local carriers," Sawchuk says. "While the agency did not mandate its adoption, it told carriers the tool could be helpful. As a result, the criteria contained in it have been utilized by numerous Medicare carriers and widely implemented by practices to establish MDM rules on the front end of the process as well."
 
The Marshfield Clinic Audit Tool clearly outlines ways to establish specific levels of history and PE. In addition, it quantifies activities related to MDM, like the number of diagnoses and/or treatment options, as well as amount and/or complexity of data being reviewed. It also provides guidance on the risk of complication and potential for morbidity or mortality.
 
"Coders are probably used to thinking of this as the 'point system,'" Pride explains. "Using this tool, they can go through the documentation and, referring to the worksheet, assign various points for the physician's work. For instance, when determining the complexity of treatment options, they would assign one point for an established problem, but two points for an established problem that is worsening. A new problem with no additional workup planned earns three points, while a new problem with additional workup is assigned four points."
 
"Using this worksheet, coders can assess the values assigned to different tasks, which result in an aggregate number," Sawchuk says. "This, in turn, constitutes a specific level of MDM."
 
Note: Copies of the E/M Documentation Auditors' Worksheet can be ordered from the Medical Group Management Association by calling (303) 397-7888.

Pride says that the nature of the presenting problem (NOPP) in the ED also affects level of service, especially when 99285 is reported.
 
"Each of the definitions for codes 99281-99284 is only three lines long," Sawchuk points out, "while it is five lines long for 99285. This is known as the '99285 caveat,' and it provides a clinically based exemption from the three key components." The definition for 99285 notes, "Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status."
 
"The rationale behind this rests with the difficulties encountered in the ED," Sawchuk says. "How can a comprehensive history be obtained from an unconscious patient with no accompanying family member, for example? In another instance, a 20-year-old male patient is brought in with a knife in his left anterior thorax. When the physician checks the patient's pulse, he notes that the knife quivers with each heartbeat, indicating that the blade is in or very near the heart. At that point, the ED physician does not take the time to conduct a full PE. Instead, he immediately begins administering fluids through a large-bore intravenous line, types the patient for blood and sends him to the operating suite. If the whole service takes less than half an hour, it can't be reported as critical care."
 
Because of the severity of the presentation, a level-five would usually be assigned. "It's understood that, in cases like this, the NOPP trumps the key components," he says. "When you consider all of the factors that influence ED service codes, NOPP is often the most important aspect."