ED Coding and Reimbursement Alert

Fall has fallen so cold and flu season can't be far behind. That means an upsurge in visits to the emergency department. "It happens every year," says Tracie Christian, CPC, CCS-P, director of coding for ProCode in Dallas. "ED physicians will see many patients presenting with symptoms like fever, congestion, coughs, nausea and aches and pains throughout the late fall and winter months." Although these are generally not considered emergent conditions, patients without a regular physician may rely on ED staff to treat these symptoms. In other cases, patients may not want to wait for their physician's regular office hours (e.g., over the weekend), or they may have a worrisome or sudden aggravation of symptoms.

 
When reporting these services, Christian says, it is important for ED coders to assign the proper diagnosis codes to ensure payment. "Because colds and flu aren't regarded as true 'emergencies,' ED physicians may experience denials if the reported diagnosis code doesn't justify the medical necessity of an emergency-room visit," she says.
 
Historically, coders debated whether it was more appropriate to report the signs and symptoms that prompted the patient's visit, or the final diagnosis as established by the ED physician. Today, it's acceptable to report the signs and symptoms as documented during the history and physical exam portions of the visit. Coding experts cite two reasons for this position:

 
1. Typically, it's truly the symptoms that prompted the patient to visit the ED. "If the patient knows he has a cold or the flu, he probably won't go to the emergency room," Christian says. "Usually, he is experiencing a relatively severe symptom or is in great discomfort, and is concerned that something more serious may be contributing."

 
2. Given a choice of reporting signs and symptoms as opposed to a final diagnosis, symptom codes often result in a greater percentage of claims paid. "Most HMOs and PPOs have a built-in list of ICD-9 codes outlining what conditions warrant an ED visit and colds and influenza seldom appear on that list," says Todd Thomas, CCP, CCS-P, president of  Thomas and Associates, an emergency physician coding, compliance auditing and staff training firm based in Oklahoma City. "When appropriate, it's in the best interest of the physician to report the symptoms as documented."

 
When assigning diagnosis codes, Thomas says, he recommends reviewing the physician's notes and assigning those that specifically reflect the reasons for the encounter. For instance, a patient with an apparent head cold may present with fever (780.6), headache (784.0), nasal congestion (478.1, other diseases of nasal cavity and sinuses) and cough (786.2). After examination the physician diagnoses a viral upper-respiratory infection (487.1, influenza, with other respiratory manifestations).  "If all of these symptoms appeared in the documentation, I would typically report the fever as the primary diagnosis," he says. "Fever appears on nearly every payer's list of ICD-9 codes considered acceptable for an emergency visit."
 
Christian agrees. "The rule of thumb I use is, 'code the worst first.' The physician's notes will show which of the symptoms is most severe, and that usually is what brought the patient in," she says. For instance, a child with a stomachache may begin to vomit violently in the middle of the night. Although gastroenteritis (558.9, other and unspecified noninfectious gastroenteritis and colitis) may be the ultimate diagnosis, the severe vomiting (787.01, nausea with vomiting) should be reported as the primary reason for the visit.

 
While reporting symptoms has been acceptable for professional services for some time, it has only recently been allowed for facility coding. Until about 18 months ago, the UB-92 claim form that hospitals use for Medicare beneficiaries required that the final or definitive diagnosis be reported as the admitting diagnosis (field number 76). The American Hospital Association has supported that stance. "As of April 1, 2000, however, Medicare regulations state that facilities may first code the symptoms that are chiefly responsible for the visit," Thomas says. As with physician services, this increases the likelihood that the diagnosis code will meet the medical-necessity requirements for an ED visit.
 
When reporting a definitive diagnosis of flu for professional or facility services either in the primary or subsequent position, ED coders should be aware of the distinctions between various types of flu and their corresponding ICD-9 codes. Among those listed within the category of influenza (487) are:
 

487.0 influenza, with pneumonia
 

487.1 influenza, with other respiratory manifestations
 

487.8 influenza, with other manifestations.

 
Coders should note that influenza codes must always carry a fourth digit. In addition, 487.8 is assigned for flu with gastrointestinal symptoms. However, this code should not be confused with the one for intestinal flu (008.8, other organism, not elsewhere classified), which appears in the infectious diseases section of the ICD-9 manual and typically indicates a bacterial infection not a viral infection.

 
Of course, the patient's visit to the ED is reported with the appropriate E/M code (99281-99285, emergency department visit). And, Christian says, a number of other professional services may be provided and billed. "A patient may arrive at the ED with a high fever and severe cough, for instance, and the physician may order a chest x-ray to determine if the patient is suffering from bronchitis or pneumonia. In many cases, the hospital would report this service. But if the ED physician interpreted the x-ray for some reason, he or she may report the professional service (71020-26, radiologic examination, chest, two views, frontal and lateral, -professional component), while the facility bills the technical component (71020-TC, radiologic examination, chest, two views, frontal and lateral, -technical component)."
 
Cold and flu symptoms rarely prompt laboratory services, Christian adds, with the exception of occasional rapid strep tests, which would be reported by the facility.