ED Coding and Reimbursement Alert

Is your emergency department falling prey to these issues?

When you evaluate your ED’s coding practices, you hopefully don’t notice a plethora of errors among the charts. But it’s possible that you may observe problematic coding, documentation, or compliance practices now and then — and in some EDs you may see the same issues repeatedly.

Although some ED coders say they’ve rectified most issues they see, others still come across problems. We talked to several coders to find out the most common issues they encounter in emergency departments, along with information on how to avoid them.

Problem 1: Writing “Old Records Reviewed”

Documenting “old records reviewed” in a chart can be confusing for coders, said Marie Franklin, MBA, CPC, national director of coding, education, and audit with AdvantEdge Healthcare Solutions. “What does that mean? How is that relevant to today’s visit?” she asks. “Elaborate a little more on that if you want credit for it. I need to understand how this affected decision making.”

Remember: The concept of “old records reviewed” is a proxy for the amount and complexity of data reviewed listed in the Marshfield Clinic Scoresheet to help codify medical decision making (MDM). This notes that if the presenting problem requires a review of old records for consideration of diagnosis and treatment, that could be suggestive of a higher level on MDM and perhaps a higher-level visit code. While “old records reviewed” meets the minimum standard, a best practice would be a short summary or notation of a relevant data point, such as “prior creatinine normal.”

Problem 2: Missing Documentation That Supports Higher Code Levels

Many physicians simply lack the documentation that would allow them to code to the highest level, says Elaine Dunn, DHA, RRT, RPSGT, CPCO, vice president of revenue integrity and centralized coding with Change Healthcare in Alpharetta, Georgia. “This can be related to not capturing all of the past medical history, not clearly documenting time spent providing critical care, or failing to clearly understand and capture the documentation requirements for each of the core E/M elements (presenting condition, patient history, exam, and medical decision making),” she says.

She notes that this issue is prevalent enough that she sees it much more frequently than she’d like. “Each day we see lost opportunities where if just a few extra statements or times had been captured, it could have resulted in the ability to bill critical care time or take a level three to a level four based on more robust MDM documentation. In practice, as we are reviewing the charts, experience will tell us what the clinical sequelae likely was, but all that matters when it comes to assigning a CPT^® code is the documentation that is present to support that code. Unfortunately, the old rule of ‘if it was documented it wasn’t done’ has not changed when it comes to compliant billing and continues to be the root of most of the lost opportunities we see.”

Problem 3: Failing to Document Medical Necessity for Tests

Another commonly seen issue in the ED is when a physician orders a test such as an EKG without first following required protocols that would support medical necessity. “If a patient has chest pain, there’s likely a chest pain protocol that leads them to order the EKG, but the documentation may not support the order,” Franklin says. “In that case, the insurer could deny as not medically necessary, and then the ED physician won’t have the documentation to support it other than saying ‘it was part of our protocol.’”

She, therefore, teaches physicians to document why an EKG was important. “Did the patient have a history of chronic heart failures? Did the physician note an arrhythmia? We need to see that in the notes,” she adds. While the provider does not need to specifically state “I ordered an EKG to rule out” a specific condition, the thought process and reasoning should be apparent from the totality of the medical record.

Problem 4: Accurately Conveying Risk Levels

Physicians sometimes need to be reminded to document their thought processes to help the coder select the level of risk that applies to their E/M visit, says Terri Tamez, CPC, CEO of Phoenix Coding and Consulting Service. “The ‘risk’ of the presenting problem or potential illness/injury does factor into the medical decision making,” she says. “Document the differential diagnoses considered that required additional workup or treatment. This helps the coders know if this patient has a potential high-risk problem.”

Filling in these blanks will provide anyone who reviews your documentation with a more complete record that is easier to defend against payer scrutiny and denials. “It also helps the coders give you full credit for the services you provided,” she adds. “Get paid for what you do!”