ED Coding and Reimbursement Alert
Are You Making the Most of
Translating coding advice into practice means whipping out the patient encounter forms and mapping theory onto real patient scenarios that cumulatively cost you valuable dollars. Concentrate on Facts: Piece Apart E/M Documentation Follow along with this detailed analysis, and practice similarly scrutinizing other ED claims. Your hard work will lead to more precise coding that captures all the elements contributing to E/M levels. Key for Unclear Bracketed Terms: Follow Through: Piece Together the Analysis The appropriate E/M code for this case is, Blakeman says: These listed procedure codes carry with them major questions marks. See "Mistakes in the Physician's Documentation" below for more on this ambiguity. You can count the additional workup planned for continuing care outside of the hospital, Thomas says. Additional workup, however, does not include work done during the visit, such as labs, x-rays, etc. "That [method] would put all your patients at four points," leaving no way to differentiate between moderate and complex decision-making, he says.
The following patient history and physical examination report is fully dissected, showing you where the E/M points and money are in your physician's documentation. The report comes from James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa. In the physician's notes, Blakeman inserts flags that help break down the E/M components. At the beginning of the example is a key for understanding the bracketed labels that are not self-evident. Take note, however: This history and physical documentation is not perfect that would make coding too easy!
Chief Complaint: Abdominal Pain [PertComplaint] [RPPMod] [NewNMMore]
History: Patient is a 19-year-old female who presents to the ED with a chief complaint of abdominal pain [NewNMMore]. The pain had started about two days prior to her evaluation [Duration] and was worse in the morning [Timing]. The pain had increased in severity the morning of admission to the department and was described as moderate [Severity]. The pain was bilateral and lower in the abdominal area [Location]. The patient had nausea [Assoc Symp] and two episodes of vomiting [Assoc Symp, which you count only once toward the history of present illness (HPI), either here or previously or later in the paragraph].
She denied any urinary difficulties [RS-GU] or bowel symptoms [RS-GI]. She had recently noted abnormal menstrual periods of the last two or three months [Assoc Symp and RS-GU]. She also noted an occasional or intermittent vaginal discharge [Assoc Symp, RS-GU]. She also admitted to being sexually active with no form of birth control being used [Soc]. She had no other significant past medical history [Pmed]
Physical Exam: The patient appeared as a young female [Const-GA] with a complaint of severe lower abdominal pain. The patient's temperature was 100.5 degrees, blood pressure was 105/60, pulse was 82, and respiratory rate was 26 [Const-VS]. Physical examination of the patient revealed unremarkable cardiac [Cva-Neg] and chest exam [Che-Neg]. Abdominal exam revealed a soft abdomen [GI-Pal] with decreased bowel sounds [GI-Aus]. The patient exhibited bilateral lower abdominal pain to deep palpation [GI-Pal]. The pain was greater in the right quadrant, and there were signs of local rebound tenderness [GI-Pal]. No masses of organomegaly were noted [GI-Liv]. Rectal exam was benign [GI-Rec].
The patient underwent a routine pelvic exam, which revealed a tender cervix [GUF-Cer] with minimal vaginal discharge [GUF-Vag]. No bleeding was noted. There was right adnexal pain, but no masses were noted [GUF-AdP].
Laboratory and Procedures: The patient had a routine CBC, electrolytes, amylase and urinalysis, as well as serum pregnancy [Order]. The results of these tests revealed a white blood count of 11,500 and a negative serum pregnancy. Other tests were unremarkable. In view of the patient's condition, she underwent routine ultrasound study of her lower abdominal and pelvic region [Order]. The ultrasound revealed a right-side ovarian cyst [Cmplx Test] with a small amount of free pelvic fluid and was otherwise unremarkable.
The patient was treated in the ED with intravenous fluids [R-OptionLow] and parenteral pain medication [R-OptionHigh]. Her course improved in the department, and her pain resolved. Her vital signs remained stable [Const-VS]. She was discharged after a total stay in the ED of two and a half hours.
Impression: Abdominal pain [RPPMod] secondary to ruptured ovarian cyst [NewNMMore].
Treatment: The patient was treated with anti-inflammatory pain medication [R-OptionHigh] and referred to her obstetrician/gynecologist for a follow-up ultrasound within 24 hours.
For this illustration, the Medicare 1995 documentation guidelines are used. If given a choice between the '95 and the '97 guidelines, "use the set that is most beneficial to the physician," and in the ED, that's the '95 guidelines, says Todd Thomas, CPC, CCS-P, president of Thomas & Associates, a company ensuring reimbursement for emergency physicians in Oklahoma City.
Possible procedure codes include, Blakeman says:
E/M Breakdown: The E/M breaks down into a level-four history, a level-four physical exam, and level-five medical decision-making, Blakeman says. This case, therefore, warrants a level-four E/M service, although the medical decision-making would have allowed a level-five ED E/M, 99285, he says.
The history includes an extended history of present illness (HPI) with four descriptors and extended review of systems (ROS) with at least two systems noted, Blakeman says. For the second E/M component, the physical exam, the physician performed a detailed exam because you have six organs, more than enough for a level-four exam according to '95 E/M guidelines, he says. The third E/M component, the medical decision-making (MDM), qualifies as "high," given that the case involves a "new, non-minor" presenting problem "needing more assessment," which requires "extensive" management options and data. The risk associated with the IV pain medication is "high," he says.
Despite the "high" MDM, you cannot report the highest-level E/M because to report an E/M level, your documentation must "meet or exceed all three of the components to assign a given level," Thomas says. That is why the correct answer is 99284.
Mistakes in the Physician's Documentation: You should note that elements are missing from the physician's documentation that could have bumped up the E/M level, maybe not in this case, but in others. It lacks a truly sufficient ROS, and it has a potentially insufficient physical exam, two obvious documentation problems.
Blakeman says the physician also made the mistake of not noting:
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