ED Coding and Reimbursement Alert

Primary psychiatric visits to the ED are common. However, the acutely suicidal or psychotic patient can be a challenge to the ED physician and coder. Acute cases can usually be coded 99285 (emergency department visit for the evaluation and management of a patient ...) because the patient's psychiatric illness typically poses a threat to life or bodily function. But the physician must clearly document all the elements required to support a level-five service.
 
"Many psychiatric visits are from chronic 'frequent fliers' who, after careful screening and medication refills, can be released," says Michael Granovsky, MD, chief financial officer of Greater Washington Emergency Physicians, a five-physician ER staffing group in Maryland. "However, level-five cases require an extensive workup and thorough documentation, and these cases often result in the need to admit the patient."
 
Initially, the physician screens for metabolic/organic causes to determine if this contributes to an acutely suicidal or psychotic patient's decompensation. This usually involves a complete history -- both medical and psychiatric -- and a physical exam.
 
"It would not be uncommon for the history to be in-depth and satisfy 1995 guidelines for 99285," Granovsky says. "Certainly an exam of eight organ systems would also be common, also satisfying 99285. The medical decision-making (MDM) is generally felt to be moderate and could be coded 99284 (emergency department visit for the evaluation and management of a patient ...). If there are additional complicating factors, such as chest pain or acute mental-status changes, these cases may be elevated to 99285."

 
Scenario: Police bring a 48-year-old female to the ED after she is found wandering in traffic. She appears to be responding to internal stimuli and on further questioning is withdrawn, but she admits to hearing voices. She has given no indication of plans to hurt herself, but her thoughts are very disorganized and her responses are frequently inappropriate. Her past medical history is obtained from the family via phone, and they report she has a long history of schizophrenia (295.xx) and substance abuse (305.xx) and sometimes decompensates, but never to this extent.
 
She has been off her medication for some time. The physician gathers a complete history by speaking with the family. A full physical exam is performed, which yields a finding of a swollen left wrist (729.81) and a large occipital hematoma (920). Based on her severe agitation (307.9), the doctor administers IV Haldol and performs screening labs for the metabolic causes of her agitation. Wrist x-rays are taken, and to rule out a subdural hematoma the patient receives a head CAT scan.

 
Her lab results, head CAT scan and wrist x-rays come back normal. Her agitation is controlled with frequent doses of Haldol and Ativan. Because the current hospital does not have inpatient psychiatric services, the patient is transferred to a large regional hospital with an inpatient psychiatric ward. Hospital admission is determined after discussing the situation with the on-call psychiatrist, who knows the patient well.
 
Coding the case: The history and physical exam can be coded as a level five. The MDM in this case is complex and would be coded 99285. The transfer to the regional facility adheres to current Emergency Medical Treatment and Active Labor Act (EMTALA) rules due to the need for a higher level of care, formally obtaining an accepting physician and stabilizing the patient prior to transfer.
 
"Many of our psychiatric visits code out as a level five," says Lorraine Began, CPC, billing compliance monitor of the MetroHealth System in Cleveland, "usually because the patient is in a state that poses a potential threat to himself or herself or to others."
 
To bill legitimately at a level five, all three ED E/M services -- history, exam and MDM -- must be equal in the level of service, Began says. In other words, the history and exam must be comprehensive and the MDM must be complex.
 
Sometimes a history cannot always be obtained because the patient is comatose, unconscious or chemically paralyzed. In these cases the ED physician can apply the emergency room acuity caveat. CMS adopted this CPT coding principle. This allows a physician to defer the usual requirements of performing the key components of 99285 if the patient's condition and mental status do not reasonably allow these elements to be fully provided, and if the patient's presenting problem(s) are of high severity and pose an immediate, significant threat to life or physiologic function. However, some regional Medicare carriers apply the caveat to only the history component, while others apply the caveat to both the history and examination components, but not the MDM. Physicians should state why the caveat is being invoked in their documentation of the patient encounter.

 
According to Medicare, 90801 (psychiatric diagnostic interview examination) may be used in the ED because there are no "place of service" restrictions. But detailed documentation is required for reimbursement. Although 90801 is rarely used in the ED, the service would qualify for 90801 if the documentation supports a psychiatric diagnostic or an evaluative interview that includes a history, mental status and disposition, communication with family or other sources and ordering and medical interpretation of laboratory or other medical diagnostic studies.
 
A psychiatric diagnostic interview examination consists of elicitation of a complete medical and psychiatric history, a complete mental-status exam, establishment of a tentative diagnosis, and an evaluation of the patient's ability and willingness to participate in the proposed treatment. Information may be obtained from the patient, other physicians and/or family. There may be overlapping of the medical and psychiatric history, depending on the problem.
 
A psychiatric diagnostic interview examination is not considered to be medically reasonable and necessary when the patient has a previously established diagnosis of organic brain disorder (dementia) unless there has been an acute and/or marked mental-status change requiring a diagnostic psychiatric exam to rule out additional psychiatric or neurologic processes that may be treatable.
 
The interview should also be conducted once, at the outset of an illness or suspected illness. It may be performed again for the same patient if an extended hiatus in treatment occurs or if the patient requires admission to an inpatient status for a psychiatric illness. Routine re-evaluation of the patient in the chronic-care setting is not considered medically necessary. The ICD-9 codes that support medical necessity include 290.0-318.1 (mental disorders).

 
Scenario: Parents bring in their 17-year-old daughter. She has ingested alcohol and prescription medications, has lacerated her wrists and demonstrates suicidal tendencies (300.9). She is agitated with her parents for bringing her to the ED and refuses to answer many of the ED physician's questions. Her parents state that she has a history of depression and has received psychiatric counseling in the past.
 
The ED physician performs a comprehensive examination and orders a complete blood count and a toxicology screen, along with IV fluids for rehydration. He or she also requests a psychiatric consultant to participate in the evaluation of this patient. The decision is made to transfer her to a juvenile mental-health facility for overnight observation.
 
Coding the case: Code this example with 99285. The documentation and MDM support this level E/M. Because of the nature of the exam, the ED physician performing the consult/examination may choose to assign 90801. Coders may be unfamiliar with this code because ED physicians often seek consultation from psychiatrists who would typically assign it. The ED physician uses an E/M code because the consulting psychiatrist will probably assign 90801, which helps the payer clearly identify the services, preventing reimbursement conflicts.