ED Coding and Reimbursement Alert

 Beef up paper trail to secure ED reimbursement

For many ED physicians, the care they deliver to hospital patients doesn't stop in the emergency department. Generally, these services don't meet requirements for a consult - but read this to find out when you can get reimbursed for them using 99231-99233 (Subsequent hospital care).

Write It to Earn It

"If your physician just goes to the floor to perform a quick procedure such as intubation and writes a short procedural note with otherwise sparse documentation, you may be missing out on an opportunity to code for this additional E/M service," says Michael Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems in Stoneham, Mass.
  
The bottom line: Underdocumenting can result in undercoding, which in a year could cost the emergency physician's practice thousands of dollars. For a number of reasons, including contractual obligations, after-hours resource limitations, or general clinical responsiveness, many ED doctors find themselves responding to the inpatient floor to evaluate patients in distress.
 
For example, suppose the ED physician thinks that his documentation won't support a higher-level subsequent-care code, so he always uses 99231. Because 99231 pays about $20 less than 99232, downcoding these claims just 10 times in a month could cost a practice $2,400 per year.

Specify 2 of 3 E/M Components

To avoid underreporting and underpayment for subsequent-care claims, make sure the physician's documentation assigns two of the key components to the following daily subsequent-care codes for a patient's evaluation and management, rather than the three of three components needed for ED E/M services.
  
Remember: The key components are the history, the physical exam, and the medical decision-making (MDM), says Brett Baker, third-party payment specialist in Washington, D.C.

  99231 - ... problem-focused interval history, problem-focused exam, straightforward or low-   complexity medical decision-making
  99232 - ... expanded problem-focused interval history, expanded problem-focused exam, moderate-   complexity medical decision-making
  99233 - ... detailed interval history, detailed exam,  high-complexity medical decision-making.
 
"The extent to which a physician performs history, exam, and MDM determines the level of service that is selected for a subsequent hospital care visit," Baker says.
 
Use -59 for Separate Care

If the ED physician is called to the floor to evaluate a patient already treated by the ED group earlier that day, you may need to append modifier -59 (Distinct procedural service) to alert the payer that two separate evaluations took place, Granovsky says.
 
For instance, if the ED group evaluated a patient in the morning, and that patient then went to the operating room for a cholecystectomy, you would report the initial ED visit with the 9928x (ED E/M) codes. But suppose that a few hours later, the patient is having shortness of breath and the ED doctor is called to the floor. For this second E/M service, you'd report a code from the 99231-99233 set and append modifier -59, Granovsky says. And, you may want to check your local payer's policy and submit the physician's notes.
  
Count 2 to 7 Body Systems

Suppose the ED physician is called to the floor to see a patient who fell out of bed and injured his hip. He must typically examine and document at least two to seven body areas or organ systems as part of a detailed examination to report the visit using 99233.
 
Although the two-to-seven rule is not specifically stated in the documentation guidelines (DGs), you can infer from the DG notes that a problem-focused exam requires documentation of one element of the physical exam and that a comprehensive physical exam requires documentation of eight or more organ systems. That means expanded problem-focused and detailed exams, by default, would require documentation of somewhere between two and seven body areas or organ systems, Granovsky says.