ED Coding and Reimbursement Alert

One of the most common challenges to the ED coder is identifying the correct evaluation and management (E/M) level of service for an ED visit, and determining the correct modifiers to apply to that code when E/M services are performed in addition to procedures. This months case provides an opportunity to explore the multiple options available to the coder when differentiating a procedure service from an E/M service. In addition, it offers a challenge to the coder in correctly identifying the level of E/M service provided, as well as determining the level of repair performed by the emergency physician. (Please see the box on page 22 for the patient chart information that was available to coders in this case.)

Determining Level of Service

The presentation of this patient via ambulance and immobilized on a backboard provides the first clue that a potentially serious injury may have occurred. In addition to the obvious laceration to the face, the patient is complaining of syncope, which requires further investigation by the emergency physician.

From the coding perspective, it is always beneficial for the physician to address each component of the patients history separately so that the coder can easily select needed elements to justify a particular level of service.

Although components of the history are combined in this example, the elements are clearly identified. The coder must review the entire history narrative and attempt to differentiate the elements of each history component.

Note: When selecting documented elements of the history to justify a level of service, there can be some swapping of terms where they apply to the history of present illness (HPI), past medical history and review of systems (ROS). There remains, however, much controversy over the use of a given element for more than one history component. For example, weak and nauseated could qualify as an element for both the HPI and a gastrointestinal ROS. Common sense tells us the statement could be used for both. However, in the past few years, numerous statements have been made by HCFA representatives in private correspondence and public comments that references may only be counted as an element once. Thus, if the claim is reviewed by a carrier or private payer, it would not be unusual to see a term allocated to only one element, either the HPI or the ROS.

Scoring HPI

The following elements of the HPI were identified: location (nose and forehead); associated signs and symptoms (neck pain, weak, nauseated); context (lost balance while cleaning hot tub); duration (this afternoon, undetermined duration).

Level of HPI: Extended.

Scoring ROS

A review of systems is generally considered to be an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms the patient might be experiencing or has experienced. Portions of the ROS could qualify for either an HPI element or past medical element to justify a particular level of service. In this case, the emergency physician seems to focus primarily on the neurological concerns that may have resulted from the fall. Due to the patients history of cervical spine arthritis, there is also focus on facial and neck trauma.

Since we have identified four elements of the HPI, the maximum amount required, most of the additional statements recorded in the history may be counted as elements in the ROS. These additional elements identified include: neurological, musculoskeletal, cardiovascular.

Note: the diplopia double vision was included in neurological; the malocclusion in the musculoskeletal.

The reference to weak and nauseated qualifies for a gastrointestinal element if the coder chooses to use the statement in the ROS rather than an associated sign and symptom in scoring the HPI. However, there are not enough other elements contained in the ROS to qualify this case for a complete ROS (10 or more are needed), so it is not critical to the scoring to use it.

Level of ROS: Extended.

Scoring Past, Family and Social History (PFSH)

The physician provides some past medical history relative to the current potential musculoskeletal injury. The patients medical history is documented as: generally good health; history of cervical spine arthritis . . .; has had no disc injury and no neurologic deficit. There is no family or social history recorded.

Level of PFSH selected: Pertinent.

Overall Level of History Selected: Extended.

Scoring Physical Examination

The physical examination was scored using the 1995 documentation guidelines and identified the following body areas and organ systems: body area general inspection; head including face, abdomen, and extremities (4). Organ systems examined include: constitutional, cardiovascular, respiratory, neurological, musculoskeletal, and skin.

Note: To qualify as examined, generally these systems should be documented as visually examined (skin), auscultated, percussed and/or palpated.

Level of Physical Examination: Twelve body areas and organ systems have been identified. Unless eight or more organ systems are identified, the physical examination does not qualify as a comprehensive examination. Thus, a detailed level (5-7 body areas/organ systems) is assigned.

Scoring Level of Medical Decision-Making

Medical decision-making (MDM) consists of three distinct components: the number of diagnoses or management options considered, the amount and complexity of data or tests reviewed, and the level of risk. In this case, the MDM should be scored as follows:

1. Number of diagnoses or management options. This patient has new problems that require work-ups to determine the extent of the injuries (laceration and musculo-
skeletal), as well as the potential for neurological problems.
Level assigned: Extensive.

2. Amount and/or complexity of data reviewed. EKG with interpretation; lab tests, x-ray with interpretation and CT scans.
Level assigned: Extensive.

3. Risk. The presenting problem is high risk due to the possible injuries and neurological changes that pose threat to bodily function as underscored by the need for CT scans. Diagnostic procedures ordered are low risk; management options selected are of moderate risk.
Risk Level Assigned: High.
Overall Level of MDM Selected: High.
Overall E/M Level Assigned: 99284-Detailed.

Choosing Procedure Codes

Cases such as this provide the element of surprise and offer a challenge for the coder because the complete treatment is not provided by the emergency physician.

One 1.5 cm gouge-type laceration was identified, and the type of closure was determined by phone consultation with the plastic surgeon, who revised the laceration within a few days. (The patient was treated in the emergency room on a Monday at 4:45 p.m.) The emergency physician closure is simple, single layer.

Wound closure: 12011*.

Choosing Interpretation Codes

If the emergency physician chooses to bill for diagnostic interpretations, both the EKG and the x-ray interpretations would qualify for separate identification depending on the individual third-party payers policy on documentation of the interpretation. HCFA guidelines generally state that the documented interpretation must include findings, relevant clinical issues and diagnosis. Each of the interpretations in this case meets that definition.

Final Code Recommendation

CPT Codes:

99284-25 Detailed E/M service with 25 modifier
to indicate that the E/M service is a
significant, separately identifiable
service performed by the same physician
on the same day of the procedure.

12011* Simple repair of superficial wounds of
face, ears, eyelids, nose, lips and/or mucous membranes, 2.5 cm or less.

93010 EKG Interpretation.

72040-26 X-ray cervical spine.

ICD-9 Codes:

802.0 Closed fracture of nasal bones

873.42 Open wound of head, face, without
complications.

780.79 Weakness (generalized).

723.1 Cervicalgia.

E888 Accidental fall.

Note: Although the physician listed a diagnosis of acute nasal fracture, the CT scans referenced in a later addendum (available only after the initial codes were determined) indicate that all were negative for fracture. The diagnosis of probable syncope cannot be coded as syncope, but the code for weakness can be selected.

Tips for Using the 25 Modifier Correctly

Remember, for those cases without additional injuries or medical complications, according to the 1999 CPT manual, the use of the 25 modifier does not require reporting of a different diagnosis but may be caused or prompted by the symptom or condition for which the procedure and/or service was provided. (For more information on reporting procedure codes and E/M codes with and without the -25 modifier, see the article on page 19 of this newsletter.)

The January 1999 CPT Assistant clarifies the -25 modifier as, used to indicate that . . . the patients condition required a significant, separately identifiable E/M service above and beyond the other service provided, or beyond the usual preoperative and postoperative care associated with the procedure performed.

According to the September 1998 issue of CPT Assistant, CPT codes for procedures do include the evaluation services necessary prior to the performance of the procedure (e.g., assessing the site/condition of the problem area, explaining the procedure, obtaining informed consent), however, when significant and identifiable (i.e. key components/counseling) E/M services are performed, these services are not included in the descriptor for the procedure or service performed.