ED Coding and Reimbursement Alert

When most ED physicians look at a medical chart, they use a top down approach: take the history, perform the examination and then document the medical decision-making (MDM) they used to arrive at a treatment decision.

However, coders and billing companies in charge of reporting services by emergency physicians should understand that Medicare auditors and most other payers look at charts very differently, advises John Turner, MD, FACEP, medical director of documentation and coding compliance for TeamHealth Inc., an emergency physician staffing company based in Knoxville, TN. Understanding how to code a chart from the bottom up can ensure that emergency evaluation and management (E/M) services are reported accurately and can take much of the complication and worry out of reporting these services.

Most auditors will try to figure out the overall value of the chart first, advises Turner. When you think about it, when a patient goes to the emergency room for treatment, they dont really care what is written in the medical history or what type of exam is performed. The only thing they really care about is, they were seen by the physician, he came up with a diagnosis, performed any tests that were necessary, gave them medication, and got them out the door. What they are paying for is the medical decision-making process that the doctor goes through. That is the real worth of the chart. Medicare knows this, and that is what they look for first.

What is Bottom Up Auditing?

Medicare auditors and most other payers, Turner contends, will look at a patients chart and first determine the level of medical decision-making. They use that level as the basis for the level at which the chart most likely will be coded. Then, the auditor will go back up to the history obtained and the exam performed and check the documentation to determine whether it supports the level indicated by the decision-making involved.

A Medicare auditor will look at a chart and look first at the bottom, they will put all of the medical decision-making data into their table (See previous article on E/M code 99282 in the September issue of ECA on page 67.) and come up with a value for that level, for example a Level 4. Then, they take that Level 4 and go to the top of the chart to the history and physical to see if the documentation supports a Level 4. If the documentation isnt there, they downcode it.

Using This Method to Your Advantage

Coders can learn to look at an emergency physicians charts in the same way and educate the physician about where documentation might need to be improved to consistently bill an appropriate level for E/M services.

One of the big things that upsets physicians is us always asking for more documentation, Turner relates. They say, You are only doing that to increase the value of the chart so you can get more money. But, if you code based on the medical decision-making, their documentation can never result in a higher code. It is just the lack of documentation that can result in a lower code assignment.

Using medical decision-making as a guide ensures that the code assigned is based solely on two things: the severity of the illness or injury, and the amount of decision-making the physician had to use to arrive at a diagnosis.

When you are choosing a level of service, your medical decision-making runs the level of service, agrees Pat Moore, vice president of reimbursement for Healthcare Business Resources Inc., an emergency medicine billing company in Durham, NC. You can document as much history and physical as you want to, but it still comes down to the decision-making that drives the service.

Turner recommends coders begin by looking first at the presenting problem to get an idea of what the visit was about. Next, the coder should move directly to evaluating the medical decision-making used to arrive at a base code. Finally, they should apply their selected set of documentation guidelines to the documentation of the history and physical performed. If the documentation supports the base level, it can be reported. If the documentation is lacking, the chart must be downcoded from the base level to one supported by the documentation.

If you value the chart at a Level 4 for the decision-making, then it doesnt really matter if the doctor writes a 20-page note for the history and physical. The chart can never get above a Level 4 because the decision-making doesnt warrant it, Turner explains. Medical decision-making is the one area the doctor cant fudge, unless he lies about what he did, about performing a chest x-ray or talking with another doctor. But 99.9 percent of doctors are not going to do that.

If coders employ this method (of basing the code on the decision-making level and educating the physicians about it) the physicians will be more willing to listen to pleas for better documentation, he believes.

You can use this as an educational process for the physicians, he says. You can send the charts that have to be downcoded back to them with a note: Based on the level of decision-making used, this should have been a level 4 visit, but we had to downcode to a Level 3 or Level 2 because you didnt include these X elements in your history or these other elements in your physical. You might want to take a look at that.

Code Selected Must Fit Presenting Problem

However, even when MDM is used to determine a base level for the chart, coders must chiefly consider the medical necessity of the visit, says Moore.

To arrive at a level of MDM, you only need to arrive at a particular level in two of three categories: number of diagnoses and management options, amount and/or complexity of data reviewed, and the risk of morbidity and mortality, she notes. And, I have heard people say that, If I document enough for a Level 4 in the history and then the exam, then I base my medical decision-making on the number of diagnoses and treatment options and amount and complexity of data reviewed, then I can always get a Level 4 instead of a Level 3. But, if you do more than is medically necessary for the patients evaluation and management, then that becomes an abuse of the system.

In charts that are on the line between being coded a Level 3 or Level 4 service, Moore recommends going chiefly with the risk of morbidity and mortality faced by the patient.

For a Level 4 patient, it should be someone that you must see very urgently, she explains. Not someone you must see immediately because that could be a Level 5, but someone who must be seen urgently for medical treatment.

Turner also emphasizes that he is not saying that doctors should always document more in the history and physical portion of the chart.

Some billing and coding companies across the country have gotten into serious trouble for reporting high-level E/M codes for relatively minor presenting problems, simply because the history and physical met the higher-level E/M requirements. You cant have two- or three-page histories on sore throats and then value them at a Level 4. It isnt worth it, he states.

Note: This issue is particularly important when deciding whether a visit is a Level 3 service or a Level 4 service. Both code 99283 and 99284 require the same Level of medical decision-making, but different history and physical examination requirements.

Process Makes Coders Job Easier

Many coders worry that an incorrect level of assignment will result in a fraud and abuse investigation and they may be held responsible for upcoding errors.

There is a pretty common fear that if they mess up, they could go to jail or get fined and, as a result, many undercode to beat the band, Turner says. But, if they have this objective standard, they find that it is reliable and works really, really well. And, they feel confident and more secure about their ability to assign the correct level.