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.
Two Approaches Ease MDM
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 [...]