ED Coding and Reimbursement Alert

Editors Note: One of the most complicated duties for an emergency medicine coder is reporting evaluation and management services performed in the ED. In this and following issues, we will feature an article devoted to each emergency service evaluation and management (E/M) code (99281-99285), outlining typical services provided at that level and the documentation required for each.

A 6-year-old with no history of allergic reaction presents to the ED with several small, uncomplicated ant bites to the wrist. A 16-year-old comes in for a tetanus immunization as a preventive measure for a minor puncture wound. These are some typical ED visits that would most likely be reported with the E/M Code 99281 (emergency department visit for the evaluation and management of a patient, which requires these three key components: problem-focused history; problem-focused examination; and straightforward medical decision-making).

Most of these are patients who dont have primary care physicians (PCPs) or cant get there due to a weekend or holiday or that office is too busy, states Charlene Day, BS, CMA, CMM, CPC, director of professional relations for Team Physicians of Arizona, an emergency physician group in Phoenix.

According to CPT, the presenting problems for this code are usually self-limiting and minor. A 99281 service that is specific to many EDs is the situation in which a patient is dead on arrival (DOA) at the department and the physician does not perform a workup but just officially pronounces the death.

Note: In many areas, ambulance and EMS personnel
are not authorized to legally pronounce a person dead. So, even if a person were killed instantly in an automobile accident, for example, he or she would be transported to the ED for the physician to pronounce the death and sign the death certificate.

[Pronouncing the patient dead] is very controversial because some groups dont charge for this, and some actually document any exam the physician does and charge at a higher level, notes Day.

Limited Documentation is Acceptable

Medicare utilization figures indicate 99281 is not frequently reported. Underreporting could arise because many possible 99281 visits are written off as no charge, says Day. Coders may feel that the medical record cant be coded even to that minimal level due to poor documentation, but in actuality a Level 1 is easy to meet. In most cases, even the poorest documentation should support that code.

When 99281 is overreported, it is usually due to coders being very conservative and reporting this level when the medical record would actually support a Level 2 or Level 3, she believes. (See the chart on page 64 indicating Medicare utilization figures for the emergency services E/M codes for 1997.)

Documentation Requirements

For the Level 1 ED E/M code, the requirements do not vary substantially between the 1995 and 1997 versions of the E/M documentation guidelines established by the American Medical Association (AMA) and the Health Care Financing Administration (HCFA).

In both versions, documentation of the problem-focused history must include the chief complaint (CC), and a brief history of the present illness (HPI), with one to four elements identified (e.g., a rash of two days duration, uncomplicated injury from a minor puncture wound, etc.). In neither version is review of systems (ROS) or past medical, family or social history (PFSH) required, says Barbara Cole, vice president of pre-billing operations for Reimbursement Technologies, an emergency medicine coding and billing company in Blue Bell, PA.

A problem-focused physical exam is the second requirement of a Level 1 E/M service, and requires documentation of the exam of only one body area or system, notes Cole. The 1995 documentation guidelines for 99281 state that the examination of at least one body area/organ system must be documented. The 1997 guidelines indicate that the exam documentation should include at least one element identified by a bullet (see below) in one or more organ systems or body areas, says Day.

Note: Bulleted items are indicated on the templates used with the 1997 documentation guidelines.

According to CPT, the following body areas are recognized:


head, including the face
neck
chest, including breasts and axilla
abdomen
genitalia, groin, buttocks
back
each extremity

Also, CPT lists the following organ systems:

eyes
ears, nose, mouth, and throat
cardiovascular
respiratory
gastrointestinal
genitourinary
musculoskeletal
skin
neurologic
psychiatric
hematologic/lymphatic/immunologic

The third component of a Level 1 service is medical decision-making of straightforward complexity.
According to CPT guidelines, straightforward means that:

1. There are a minimal number (1-5) of diagnosis options considered.

Example: Ant bites to the arm cause a rash; a minor puncture wound means the patient needs a tetanus prophylaxis. At this level, the diagnosis is usually obvious and does not require substantial differential diagnoses.

2. None or a minimal amount of medical records, diagnostic test results, and/or information obtained, reviewed and analyzed.

Example: No review of medical records data or diagnostic test results to diagnose a rash caused by ant bites or a tetanus shot for recent puncture wound.

3. Minimal risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patients presenting problems, the diagnostic procedures ordered and/or any management options considered.

Example: Ant bites and minor puncture wounds are low risk presenting problems. Diagnostic procedures, if ordered, are of low risk (i.e., an EKG, dipstick urinalysis, chest x-ray, venipuncture). Management options that would be considered minimal include orders for the patient to rest, gargle with medication, or application of superficial dressing, says Day.

Must the Physician See the Patient?

Clinically, a patient presenting with such a minor problem can be treated by a mid-level practitioner (PA, NP, etc.) independently of the attending physician, although that physician supervises the practitioner, says Day. In these cases, either the physician or a mid-level provider would see the patient and render treatment.

However, Medicare does not recognize the concept of incident to services in the hospital setting. So, if the mid-level provider provides the care to the patient, he or she must bill the code 99281 to Medicare using their own provider identification number (PIN). Their services are reimbursed at 85 percent of the Medicare allowable.

Note: The emergency physician group providing service in the ED cannot bill for the mid-level providers services
if the mid-level professional is employed by the hospital.
The hospital must report the services on its UB-92 claim form.

It is important to note that, even for low-level visits, either the physician or a mid-level provider needs to see the patient and provide the medical screening exam (MSE) in order to satisfy federal EMTALA [Emergency Medical Treatment and Active Labor Act] requirements, adds Day.

That law states that anyone presenting to the emergency department must receive an MSE and stabilizing treatment.

The hospitals multi-disciplinary committee sets policy determining what level provider is qualified to give the medical screening exam. In most cases, Day notes, the triage nurse or registered nurse cannot provide this exam; it must either be a physician or physician extender.

And, for the purpose of CPT coding for emergency department visits, the physician or physician extender, not the nurse, must provide the service to the patient.