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 bill for the CPR if he or she does not perform the chest compressions personally.

The American Medical Associations (AMA) Principles of CPT Coding, 1999, page 298, under Therapeutic Services states: Basic CPR consists of assessing the victim, opening the airway, restoring breathing (e.g., mouth-to-mouth, bag valve mask), then restoring circulation (e.g., closed chest cardiac massage). In most instances, CPR is performed prior to, with continuation during, advanced life support interventions, for example, drug therapy and defibrillation, which would be included by reporting the appropriate critical care services code(s) from the E/M section of CPT.

It is clear that the emergency physician cannot personally perform all of the functions required to manage the CPR. Therefore, it could be concluded that the CPR code is for management of the code. Ideally, however, the documentation should more clearly indicate that the emergency physician is managing the resuscitation.

Coding for Critical Care

This case is documented as 20 minutes of CPR, with additional efforts to obtain a history after the patient expired. But the physician does not clearly indicate personal involvement in management of the patient for that period of time. Generally, nursing notes can be relied on to document and support the physicians involvement in patient care. In this case, the progress notes indicate the ABG was drawn by RT (respiratory therapy), and an NG tube was placed, but there is no statement indicating who actually placed the tube. The code report indicates that the patient arrived in the ED already intubated31500 (intubation, endotracheal, emergency procedure) with active CPR in process, which was continued.

Code Assignment Based on Documentation

Consideration should then be given to whether the documentation supports the assignment of critical care code 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

For a Medicare patient, the physician would be expected to unequivocally document the time spent in personal management of this patient, according to a December 1999 Medicare memorandum. Medicare further expects a minimum of 30 minutes of personal management of the patient to bill for critical care. In this case, we have only 20 minutes of documented management in the physician notes. In addition, any time spent performing separately billable services, such as CPR, must be removed from the critical care time as reported for billing. Therefore, identification of critical care in this case is not an option because the time spent was applicable to an otherwise billable procedure.

Code 99285-25 (emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patients clinical condition and/or mental status: a comprehensive history; a comprehensive examination and medical decision-making of high complexity; significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service)the emergency E/M caveatcan be used to compensate for the small degree of history and physical examination against the high level of decision-making required. The -25 modifier is used because CPR will be billed as a separate procedure92950 (cardiopulmonary resuscitation [e.g., in cardiac arrest]).

Note: For information on the use of the emergency E/M acuity caveat, see Correctly Apply 99285 Acuity Caveat to Optimize E/M Coding, on page 4 of the January 1999 ED Coding Alert.

The emergency physician should request additional documentation and clarification to avoid the potential of future audits. Physician in-service should be conducted to underscore the need for clear, concise documentation of services and time performed by the emergency physician to assure thorough documentation of similar high-acuity cases.