ED Coding and Reimbursement Alert

The Marshfield Clinic Auditor's Worksheet can help you avoid evaluation and management coding pitfalls, but you have to work around the worksheet's own hidden traps before E/M coding becomes just a walk in the park.

In an effort to curb coding errors, experts designed the Marshfield Clinic Auditor's Worksheet, a tool for simplifying the complex rules for E/M coding. The Marshfield Clinic worksheet is a straight-forward source" " says Kent Moore manager at Health Care Financing and Delivery Systems the American Academy of Family Practices in Leawood Kan. "It is pretty consistent with or faithful to the documentation guidelines for E/M services which it was intended to be as a tool for auditing " he says.

But despite the worksheet's benefits users have expressed difficulties with the point assignments particularly in the number of diagnoses or treatment options portion of the worksheet. Overlooking this portion of the worksheet specifically the "new problem" sections often leads to lost reimbursement for work done by the ED physician or to repetitive denial claims.

The "new problem" portion of E/M coding is a "frequent discussion among ED coders " says Todd Thomas CPC CCS-P president of Thomas & Associates a company ensuring reimbursement for emergency physicians in Oklahoma City. Almost all ED patients present new problems to an examiner he says.

The two different new problem selections in Grid A of the worksheet's Complexity Section "Number of Diagnoses or Treatment Options" "New Problem (to examiner): no additional workup planned" and "New problem (to examiner): add. workup planned" have different point values. Distinguishing between the two is crucial when it comes to reimbursement for the examining physician.

Deciding whether the service merits three points for "no additional workup planned" or four points for "additional workup planned" is nothing short of a coding challenge Thomas says: "[A]s coders we have to take all the doc's training wisdom and experience and cram it into three points versus four points."

The challenge is whether to assign the ED physician only three points for "no additional workup planned" simply because the ED physician will not do the workup or to give the ED physician four points for examining a patient who will need "additional workup" from someone else.

For example a patient comes in for a fractured metacarpal (815 series) and is given IV morphine for pain control. The emergency physician performs the initial treatment but an orthopedic physician will perform the additional workup.

To find the answer look to the definition Marshfield Clinic gives for a "new problem." "New" means new to the examining physician. Because this definition attributes "new" to the examining physician the point value acknowledges all the work a physician does when encountering a problem for the first time Moore says.

Consistent with this definition the higher point values three and four acknowledge all new work not only physical but also mental work Thomas says. An emergency physician should receive additional reimbursement for a new problem with additional workup planned. He did the mental work to make the decision for additional workup Thomas says.

So give the doctor an extra point meaning check the last of "Problems to New Physicians" if the physician planned additional workup even if another physician will actually perform the workup he planned Thomas says. In the metacarpal example the ED physician planned additional workup for the patient. According to Thomas' advice the physician deserves the extra point even though orthopedics will take care of the problem.

However before you increase the points and potentially reimbursement Thomas urges you to consider one more issue: whether the planned follow-up actually qualifies as "additional workup planned."

Some coders and professionals think any work done after a patient encounter qualifies for "additional workup planned " Thomas says but that approach misinterprets the point of having a three- versus a four-point distinction he says. Additional workup plan should truly be "additional."

Thomas defines additional workup planned as workup "that is outside the scope of the physicians' standard practice." Emergency physicians who admit transfer or send/schedule patients for immediate care should receive four points for "additional workup planned " Thomas says. But other procedures commonly done in the ED department like standard blood work and x-rays CT scans and ultrasounds do not qualify for that high score.

When determining what counts as "outside the scope " you should remember that the point system is not specialty-specific Thomas says. Adjust the scope to what Thomas calls the standard scope-of-practice theory. For ED patients it is standard that they need labs and x-rays hence nurses often conduct these services based on established protocols even before the physician sees the patient. Because they are standard those services are not outside the scope of standard practice and therefore should not be recognized as "additional workup planned" by your point distribution.

In the case of the metacarpal patient you have to determine if orthopedic follow-up work is standard or beyond the scope of your practice before you assign three or four points to that section of the Marshfield Clinic worksheet.

You should ask local Medicare carriers if they use the worksheet. Although the Marshfield Clinic worksheet is a standard for many Medicare carriers the national Medicare program does not require its use. ED coders should always check with local Medicare carriers to verify its applicability.