ED Coding and Reimbursement Alert

In the emergency department, complex illnesses and serious, sometimes life-threatening, injuries are so common that many ED physicians do not appreciate the value of the services they provide and therefore may be losing out financially. Educating doctors for good documentation is key to alleviating the problem.

Although most physicians and coders worry about upcoding and the scrutiny and audits this may trigger, emergency specialists should be more concerned with possibly downcoding their charts, says Jack Turner, MD, FACEP, medical director of documentation and coding compliance for Team Health Inc., a nationwide emergency physician staffing group with affiliates in several states.

ED doctors see serious cases on a regular basis, says Turner. Thus they tend to think of these visits as not as serious. They say, Oh, a hip fracture, or That patient has CHF (congestive heart failure), Ive seen 10 this week. Frequently, Medicare will value what the ED physicians do higher than what the doctor, personally, will think. The physicians undervalue anything they perceive to not be a significant problem.

Many Level 5s Should be Critical Care

Patients in cardiac arrest, multiple-trauma car accident victims, and patients with gunshot wounds are obviously critically ill and require a high level of treatment. However, these patients are often considered by ED physicians to be Level 5 services when, in fact, many of these visits should be reported with critical care codes (99291-99292), Turner says.

One of the biggest problems we as a specialty have is that what an ED physician may think of as a Level 5 is actually critical care, and what they think of as Level 4 is actually a Level 5 service, he says. Many physicians choose E/M codes by myth and by legend instead of by the guidelines Medicare and the other payers follow. (See chart on documentation requirements for reporting 99284 and 99285 on page 83.)

ED physicians do not report critical care services in many of the instances they should, in part due to the stringent documentation requirements and time requirements set forth in CPT, Turner says.

Note: For information on the requirements for reporting critical care, see Improve Utilization of Critical Care Codes to Increase Reimbursement for Emergency Services in the January 1999 issue of ECA, page 1.

Use MDM to Drive Code Choice

A standard rule of thumb in emergency E/M coding is that, in the case of seriously ill patients, those who are admitted are usually Level 5 services and those who end up discharged home are Level 4 or lower, says Susan Callaway-Stradley, CPC, a former ED coder who is now an independent coding consultant in Augusta, SC. If I had to give a general scenario, that is what it would be. If you are looking at the Health Care Financing Administration (HCFA) documentation guidelines, to get to a Level 5 you either must have a problem that requires a consult or some additional workup, or you must have a lot of data reviewed.

Although whether or not the patient is admitted is usually a benchmark, that is not always a reliable indicator, Stradley and Turner agree.

Basically, that is true, but not all of the time, Turner explains. Coders and physicians need to get away from knee-jerk responses like Every admitted patient is a Level 5. If the documentation doesnt support a Level 5, you cant bill it.

The choice of code has to be based on the amount on history, physical and medical decision-making employed and documented by the physician, Callaway-Stradley and Turner both say.

What I have seen in the emergency room, typically, is if you get to a detailed level of history (the level of history required for 99284) you generally get all of it; you end up with a comprehensive history, says Callaway-Stradley. When you have a patient with a complex or life-threatening problem, you have all of the history, or you have the Level 5 caveat, which says you dont have to have all of the history because the condition of the patient makes that impossible. (See related section in next column.)

Educating Physicians about MDM

Coders and physicians will often view the medical decision-making very differently.

The doctor may say, Oh, I didnt do anything, it was a fractured hip, and I OKd the patient for surgery, explains Turner. But, the coder will look at the chart and see The patient was admitted, the physician ordered all of this lab work, performed an EKG, did x-rays, gave Demerol for painthat is a Level 5 chart.

Turner clarifies that the chart is Level 5 because additional workup was planned on the patient, and the physician had a large amount of data to review, prescribed medication, and certified that the patient could undergo hip surgery, which is a significant risk to the patient. These elements meet the requirements set by Medicare for high complexity of medical decision-making.

Frequently, coders will get a chart that by clinical situation should be a Level 5 service, but the documentation of the history and physical does not support a 99285; then it has to be downcoded, says Turner. When that happens, you should take the chart and go back to the physician and say, Look, this could have been a higher level but you didnt give us enough detail.

ED professional coders need to continually educate their physicians about the components of medical decision-making and how they influence the level of service provided, he emphasizes.

However, Turner also notes they can educate physicians only after the fact; the physician cannot add the missing documentation and then resubmit the chart.

No physician is going to reliably remember weeks later what he did, he says.

Benefit from Acuity Caveat

A unique feature of the Level 5 emergency E/M service (99285) is a statement known as the acuity caveat. The CPT definition for 99285 reads: 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 patients clinical condition and mental status.

The words in boldface are the caveat and have been interpreted by the Health Care Financing Administration and the American Medical Association (AMA) to mean that the lack of these elements cannot be used to downcode the level of service when a patients condition prevents the physician from obtaining certain elements of the medical history or performance of the physical exam.

For example, a patient may present to the ED either unconscious or in such a critical state that he or she is unable to give a history. Likewise, a patient may be mentally unstable or incapacitated to the point that he or she does not understand the clinicians questions and cannot provide a reliable medical history.

However, the fact that these history and physical elements are missing must be documented along with the reason why, advises Callaway-Stradley.

To invoke the caveat, documentation must include a statement to the effect of history incomplete due to patients condition or unable to obtain history because patient is unconscious, she advises.

Dont Negate Caveat

Even with that documentation, invoking the caveat is often impossible because physician documentation of the physical exam frequently negates the caveat claims, says Turner.

Physicians often shoot themselves in the foot on this because they will have a note that says, Unable to obtain history because the patient is unconscious, then they turn around and the first thing they dictate for the physical exam is, Patient alert and oriented, he explains. Turner attributes this to an ingrained dictation habit common to many physicians, which should be guarded against.

The physician is not thinking, just shooting from the hip, and this is part of their habitual dictation. But it just blows everything they said in the history, he says.

Turner advises coders to educate their physicians to take care in their dictation of the physical exam to always say exactly what takes place and what the patients condition is, he says.

Also, coders cannot go back and ask the physician to change what was dictated, even though both statements together do not make sense: Either the patient was unconscious or alert and oriented, but not both. You can just ask them to clean up their act for future visits, you cannot ask that they change documentation that has already been provided, he states.