ED Coding and Reimbursement Alert

A critically ill, unconscious patient brought into the emergency department (ED) provides special challenges to the ED clinical staffmedical history is unobtainable without the presence of an accompanying family member, and examination and treatment of the patient is difficult because the patient cannot communicate. In addition, because the patient is critically ill, the ED staff may act quickly and according to standards of emergency medical practice to preserve the patients life. The staff must carefully document the specifics of the medical encounter to enable the coders to report the appropriate level of medical care given to these seriously ill or injured patients.

The following is documentation for an actual ED encounter of a man who was found unconscious and critically ill in a laundromat.

Note: Please refer to the chart on page 38 for the documentation available for coders to report the services provided to this patient.

High Patient Acuity

Recognition that this 54-year-old patient was found unresponsive is the first step in identifying the level of medical decision-making (MDM) involved in the ED physicians treatment. The extent of MDM is usually a good overall indication of the appropriate level of evaluation and management (E/M) service for a particular visit. A high level of acuity (a seriously ill patient or one at high risk of complications) often requires a high level of physician decision-making and frequently (though not always) a detailed to comprehensive level of physical examination.

In this case, the actions of the paramedics in the field and the condition of the patient when found are both clear indications that this encounter should qualify for coding at a critical care level.

Presentation

The patient was aggressively treated in the field by paramedics with IV atropine and epinephrine. The EMS prehospital care report indicates that there was no on-line medical consultation, and there is no indication in the physicians notes that the ED physician performed pre-hospital advanced life support (ALS). Therefore, the 99288 (physician direction of emergency medical systems [EMS] emergency care, advanced life support) medical command code would not be appropriate. Upon arrival to the ED, it appears that the patient was placed on a monitor and received additional epinephrine and atropine. An arterial blood gas (ABG) was drawn by respiratory therapy, and cardiopulmonary resuscitation (CPR) and placement of a nasogastric (NG) tube were performed in the ED. The record does not indicate, however, whether the emergency physician or the emergency nursing staff initiated CPR and placed the NG tube. The physician documentation clearly indicates that they got nonconducted electrical waves, shocked the patient, gave epinephrine and continued CPR until the code was called 20 minutes after arrival in the ED. The question arises whether the emergency physician can [...]