ED Coding and Reimbursement Alert

Editors Note: This is the second installment in a series on reporting emergency service evaluation and management (E/M) codes. Future articles will cover codes 99283-99285.

Code 99282, the Level 2 emergency department E/M code, is considered the least controversial of this series (99281-99285) because of the low level of history and physical exam required to meet the level of service. As discussed in the August issue of ECA, the Level 1 code 99281, is rarely used because most ED services will require more than a simple problem-focused history and problem-focused examination from the emergency physician. (See the article, Get Paid for Many Low-Level ED Services with 99281 in the August issue of ECA, page 62.)

If there is any question about which visits should be reported with 99282, it is whether the medical decision-making supports a Level 2 or whether it can actually support a Level 3, notes David McKenzie, reimbursement director for the Dallas, TX-based American College of Emergency Physicians (ACEP).

The level of medical decision-making (MDM) used by the physician is the only factor in determining whether a Level 2 or Level 3 (99283) code is reported for the emergency department visit, says McKenzie.

According to CPT, both 99282 and 99283 require an expanded problem-focused history and an expanded problem-focused examination. However, code 99282 requires decision-making of low complexity, while 99283 requires MDM of moderate complexity.

Using the Medicare Process Correctly

And although this sounds straight forward, reporting E/M services can be very confusing if you are relying solely on the information in your CPT Manual, admits John Turner, MD, FACEP, medical director of documentation and coding compliance for Team Health, Inc., a Knoxville, TN-based emergency physician staffing company, and a member of ACEPs coding and nomenclature advisory committee.

The manual is really of no help at all, he notes. What is the difference between low complexity and moderate complexity? If you look around the country, everybody and their Aunt Martha has their own homegrown formula for figuring out the level of medical decision-making. It is very difficult to standardize or quantify it because it is an individual subjective decision.

What many groups are now doing is deciding to use the Medicare process for determining the level of MDM, Turner states.

When Medicare auditors go over patient charts, they have a specific point system for assigning values to different parts of the E/M service, Turner explains. Most carriers have audit sheets used by their personnel when evaluating a physicians charts. Although designed for use by auditors, many physician groups have requested copies of these sheets from their Medicare carriers.

In some cases, the carrier will state that they do not use audit sheets, or that they do not want to give them to you, he relates. But, if you write a letter requesting the information under the Freedom of Information Act (FOIA), usually they will provide it. In his experience, the sheets vary little or not at all from carrier to carrier, but physician groups or billing companies should request the sheets from the carriers that cover their region to be sure they have the most specific criteria.

An added benefit to using the Medicare system is that it is widely accepted as standard, Turner adds. If you have an argument with a hospital administrator and they want to know, What criteria did you use to code this chart? You can say, we use CPT and, in addition to CPT, we use the most stringent, strict guidelines for evaluating the medical decision-making level.

Note: In this article, a point system is referred to that has been compiled from several different Medicare carriers as a basis for determining Medicares method for scoring the history, physical and medical decision-making. Always contact your regional carrier for their specific requirements.

Requirements for History and Physical

According to Medicare guidelines, an expanded problem-focused history requires the documentation of one to three elements in the history of present illness (HPI). The nine available elements are: location, duration, severity, context, timing, associated signs and symptoms, modifying factors, quality, and status of three chronic/inactive conditions. This history must also include the documentation of the review of one organ system or body area for the review of systems (ROS) portion. The systems include: constitutional, genitourinary, hematological/lymphatic, eyes, musculoskeletal, endocrine, cardiovascular, neurological, allergic/immunological, respiratory, psychiatric, gastrointestinal, and integumentary.

No past, family, or social history (PFSH) is required to used codes 99282 and 99283.

An expanded problem-focused examination requires the documentation of the limited examination of the affected body area or organ system and at least one other related body area or organ system. According to CPT, the body areas are:

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

Meeting the Requirements for MDM

According to CPT, medical decision-making is comprised of three elements:

1. The nature of the presenting problem and the
number of diagnoses and treatment options
considered;
2. The diagnostic procedures ordered and the amount
and/or complexity of data reviewed; and
3. The risk of complications and/or morbidity and
mortality posed by the treatment options.

Medicare audit instructions assign point values to the number of items documented in these three elements. The number of points totaled determines the MDM level.

In order to report MDM of low complexity, according to Medicare audit guidelines, the chart must score a 2 for the number of diagnostic or treatment options considered, as well as a 2 for the amount and/or complexity of data reviewed. The presenting problems and management options selected must also be of low risk to the patient.

Under the number of diagnoses or treatment options, Medicare considers five categories:

1. Problems that are self-limited or minor (stable,
improved, or worsened)worth 1 point per
problem to a maximum of two points, according to the carriers audit sheet;
2. Established problems that are stable or improved
worth 1 point per problem;
3. Established problem that is worseningworth
2 points per problem;
4. New problem with no additional work-up
plannedworth 3 points with a maximum of one
problem; and
5. New problem additional work-up plannedworth 4
points per problem.

Most ED visits will fall in the category of a new problem with no additional workup planned, notes Turner. Most patients have not been seen by that physician before and the physician will perform no follow-up.

When considering the amount and/or complexity of data reviewed, Medicare assigns points in seven categories:

1. Review and/or order of clinical lab tests in the
Pathology and Laboratory Section of CPT, 80049-
89399worth 1 point;
2. Review and/or order of tests in the Radiology
section of CPT, 70010-79999worth 1 point;
3. Review and/or order of test in the Medicine section of CPT, 90281-99199worth 1 point;
4. Discussion of test results with performing
physicianworth 1 point;
5. Decision to obtain old records and/or obtain history from someone other than patientworth 1 point;
6. Review and summarization of old records and/or
obtaining history from someone other than atient and/or discussion with other health-care providerworth 2 points; and
7. Independent visualization of image, tracing or specimen (not simply review of report)worth 2 points.

Calculating Risk a Challenge

The most complicated part of determining the level of decision-making involved in an E/M service can be calculating the risk.

According to Medicare guidelines, low risk (the minimal level of risk to meet Level 2 requirements) consists of greater than or equal to two self-limited or minor problems, one stable chronic illness, or one acute uncomplicated problem. Diagnostic procedures ordered can include superficial needle biopsies or clinical lab tests with arterial puncture. Management options selected can include over-the-counter drugs, IV fluids without additives, or minor surgery with no risk factors.

Risk Level May Bump Up Code

ED physicians should note that an increase in risk to the patient might, in some cases, merit a higher level code in cases where the rest of the visit would go to Level 2, advises McKenzie. If you have an increase in risk, you can jump up a level sometimes, he says. For example, if you have an earache, which is usually a pretty standard Level 2 service, but you meet at least the detailed history and physical requirements and you prescribe medication for this earache, it may bump you up to a Level 4 under the 1994-95 E/M guidelines. That doesnt always mean you should bill it at a Level 4. But, sometimes it is enough to meet the requirements.

Level 2, MDM

To illustrate the correct way to calculate MDM for Level 2 emergency service visits, consider the following example:

A 28-year-old male presents in the ED with a 10-hour history of a sore throat. The physician examines the patient. He has no fever, his past health is good, and the exam only shows mild erythema of the pharynx. The physician documents that the remainder of exam is normal: no nodes, chest clear, heart sounds normal, no neck rigidity and no rash. The diagnosis is viral pharyngitis. The physician advises the patient to use ibuprofen, gargle with salt water and return if needed. No prescription is given.

The presenting problem is new with no additional workup plannedworth 3 points according to the Medicare guidelines. The sore throat is the only problem, so the visit would score a 3 for number of diagnoses or treatment options considered. There were no tests ordered, old records obtained nor independent visualization of an image, tracing or specimen. So, the chart would score a zero under amount/complexity of data reviewed. Under the calculation of risk, the presenting problem was minor and there were no diagnostic procedures ordered. However, the physician did instruct the patient to take over-the-counter medication. Medicare guidelines consider this management option to be of low risk. So, even though the presenting problem and lack of diagnostic procedures ordered would only meet the standard for minimal risk, the addition of the recommendation for medication increases the level of risk to low.

When considering all three categories to determine the final level of medical decision-making, Medicare guidelines stipulate that two of the three levels must meet or exceed the overall level of medical decision-making selected.

The first element in MDM, number of diagnoses or treatment options considered, scored a 3, which exceeds the requirement for a Level 2 exam. The second element, amount and/or complexity of data reviewed, scored 0, which only meets criteria for a Level 1 exam. However, the third element, risk of complications and/or morbidity or mortality, is considered low, which meets the criteria for a Level 2. Since, the second and third elements meet the Level 2 requirements, the overall level of MDM selected is a Level 2.