ED Coding and Reimbursement Alert

Create clearer treatment picture to lock in reimbursement

Physicians need to give a step-by-step account of their thoughts and considerations when deciding on treatment - or carriers may not give any payment to your prac-tice's account.
 
The hard part: Even if your physician keeps spotless records of history and exam, you could find yourself "downcoding" if the medical decision-making doesn't tell a good story, experts say. Think of the medical decision-making as a window to the doctor's thoughts as he determined a treatment, not just as a record of what he decided.
 
The easy part: Documenting exam and history is often easier for physicians because these elements represent concrete actions. "The more E/M services I audit, and the more different types of physicians I talk to about this, the more I realize that it's not too difficult to teach physicians how to list all the bullets in the exam," says Marcella Bucknam, CPC, CPC-H, health information management coordinator with Clarkson College in Omaha, Neb. But getting the physician to explain the thoughts behind a set of decisions is much harder.
 
Hint: Documentation systems that fit a consistent format, prompted dictation, and a solid documentation inservicing program can all help physicians keep their documentation specific and capture the required history and physical exam elements.

Emphasize Details in Documentation

Solution: To dramatize the process that goes into the final decisions your physicians make, you should encourage them to express the difficulty of decision-making. "I encourage physicians to say things like 'Deciding on the exact treatment here was very difficult,' "  Bucknam says, "instead of the cut-and-dried statements they tend to make."
 
And physicians should spell out the risk even if they don't treat a problem, says Lori-Lynne Webb, director of coding and compliance with Saltzer Medical Group in Nampa, Idaho. "If they don't treat it, what are your risk factors?" Also, what are the risks of treating the problem incorrectly? Providers should document all of these things.
 
For instance, suppose the physician orders a parenteral-controlled substance but there is no indication on the chart by the nurse or the physician whether the medication was actually administered. You should still consider that order for MDM purposes, says Kimberly Engel, CPC, coder at Infinity Healthcare SC in Mequon, Wisc. Even if the doctor doesn't administer it herself, she still had to do the decision-making to know how much the patient should receive, the risk involved, whether the patient could tolerate it, and what medication to prescribe, Engel says.

Justify Carefully When Diagnoses Differ

A 55-year-old presents with chest pain radiating to her back that is associated with exertion and bending over. She also complains of a gassy bloating and lots of burping. The treating physician thinks this could be an acute cardiac event, an aortic dissection, or gastric reflux. The physician's documentation needs to reflect the
level of concern for all three possibilities in this differential diagnosis. 

The physician then performs a computed tomography scan of the chest and a full cardiac workup, both of which are normal. The patient improves with an antacid cocktail and is ultimately discharged, and you've reported 99285 (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 patient's clinical condition and/or mental status: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity).
 
You may need to convince the carrier why the physician considered this discharged patient with a final diagnosis of gastric reflux high-risk. If the physician is able to document and communicate his concerns about the possibilities of life-threatening chest pathology, the carrier will likely be satisfied.