ED Coding and Reimbursement Alert

A patient reports to the ED in such severe respiratory distress that she cannot communicate during the history of present illness (HPI) portion of the E/M service. The patient also presents to the ED alone via ambulance, meaning there was no one else to speak for her.

How can a coder decide on the history level for this ED E/M service? Knowing an important exception to the HPI rules in ED settings will help you accurately report  these incidents. .

When a physician documents that an HPI [history of present illness] is unobtainable due to patient condition, you can invoke the caveat, explains Lori Bettencourt, CPC, PCS, coder at Pro-Medbill LLC in Hampton N.H.

Benefit: The ED caveat can prevent E/M downcoding based on the E/M HPI component. Follow this FAQ to get the lowdown on all the ED caveat rules you'll need to code correctly each time.

"In real life, ED physicians are not always able to obtain a complete history from a patient. Of course the physician should always document any history they can obtain from the patient, family or friends, EMS, nursing home, etc.," says Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass. If the history is limited, however, the caveat "allowsthe physician to receive 'full-credit' for even a comprehensive history - if you document why the history could not be obtained," Lemanski stresses.

"The caveat is a CPT exception unique to emergency medicine 99285 services. It provides an exception to the E/M content requirements when the physician is unable to obtain the required [history] information," relays Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La. This could be due to the urgency of the patient's condition or the physician's mental status.

For instance: The ED physician performs a comprehensive exam and high-complexity medical decision making for a patient, but she cannot get enough information from the patient for a comprehensive history. If you invoke the ED caveat in this instance, you might be able to report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 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 ...).

Consider this potential ED caveat scenario, courtesy of Edelberg:

A 64-year-old patient presents to the ED with altered mental status and left-sided facial droop. The physician examines the patient, but the patient cannot provide any useful history information. The physician orders a CT scan of the head, the patient is admitted to rule out a stroke. Notes indicate that the physician performed a comprehensive exam and high MDM.

In this scenario, you might be able to invoke the ED caveat if the physician documented her inability to obtain a full history, and report 99285 for the encounter.

In a perfect world, the physician would stamp "ED caveat" on each relevant claim, but coders will have to be good spotters to make the caveat work for them.

How? Coders might be able to identify caveat situations based on terms the physician uses, says Bettencourt. Some terms that could indicate a caveat if they appear in the notes include:

• history unobtainable
• history obtained by family member due to altered mental status.

Other possible keys: Lemanski offers these terms that might indicate a patient that is unable to fully

• communicate:
• unresponsive
• obtunded
• comatose
• aphasic
• paralyzed and intubated
• incoherent due to intoxication or drugs.

In order to submit a successful caveat claim, however,you need to include two specific pieces of information.

"The physician needs to indicate that the required elements could not be obtained and reference thecondition; it's not enough to document UTO [unable to obtain] without some reference to the condition," Edelberg says.

Good examples: "UTO due to patient's altered mental status"

"UTO due to patient's severe respiratory distress."

"UTO due to severity of patient's stroke.

"Physicians should document whatever elements of the history are obtainable, but it's nearly impossible to perform a complete review of systems on an unresponsive patient even if a family member is there," laments Lemanski.

Best practice: Lemanski recommends a check-off box on the history and physical form like the one below, "prompting the physician to document why the history was limited or unobtainable."

History unobtainable secondary to: ____________