ED Coding and Reimbursement Alert

Hint: Avoid writing “HPI negative” in your documentation.

Choosing the correct E/M level in the ED can be challenging due to the addition of diagnostic tests, HPI elements, and radiologic reviews in the physician’s documentation. If you have trouble deciding how much credit to give these services, check out the answers to three common ED E/M questions.

FAQ 1: Test Ordered, Not Performed

Question: Suppose a physician orders a diagnostic test, such as an electrocardiogram (EKG), but the patient refuses to undergo the test. Should the physician still get credit for the order when determining the complexity level associated with the encounter?

Answer: You should factor the physician’s order into the medical decision making or care/ treatment plan. Be sure that someone documents the fact that the physician ordered the test, but the patient refused it. If possible, you should also record why the patient refused the test.

What you should know: Your physician’s decision to order a diagnostic test can impact each of the complexity (medical decision making) section’s three elements. Physicians frequently recommend a test, but the patient declines for various reasons (for example, financial concerns or reservations about risks).

Factoring in the physician’s order makes sense, because if the physician went through the medical decision making process to determine that the patient needed a particular test, even though the patient didn’t follow through, the physician should receive credit for that, provided there is documentation of that thought process.

Example: A patient with a history of migraine presents to the emergency department with a headache that is worse than her usual pattern. The ED physician orders pain medication and a computed tomography (CT) scan of the head due to the atypical severity of the patient’s headache.

After receiving the pain medication, the patient declines the head CT, stating that she feels much better and wants to just go home. The physician urges the patient to go through with the CT scan and documents appropriate clinical and medical legal support for their concerns. Ultimately, the patient still refuses to undergo the test.

Even though the patient did not present for the study, the physician’s documentation reflects a higher level of concern, and that should be factored into the medical decision making.

FAQ 2: Understand HPI Elements

Question: A patient presents to the ED with shortness of breath. The physician documents that “the patient’s chief complaint is shortness of breath, which is not exacerbated with any specific activity and has no reported associated symptoms.” Should the physician receive credit for documenting the history of present illness (HPI) elements of modifying factors and associated signs or symptoms, even though the physician reported that no activity exacerbates the condition and no associated signs or symptoms exist?

Answer: The physician deserves to receive credit in this scenario. They provided valuable information that they gathered for a medically necessary reason, and as long as it’s documented in the patient’s medical record, it deserves to be counted.

Quick tip: Ideally, the physician would simply document that the patient’s HPI is negative. Instead, if the patient has no exacerbating activities or associated symptoms, as in the above example, the physician should put that in the documentation.

For example, in the documentation, the physician might write, “The patient relays that her problems are not related to time of day, she relays no aggravating or alleviating factors, and there are no associated symptoms.”

The bottom line: With this simple sentence, the physician would document three of the required four HPI elements (timing, modifying factors, and associated signs and symptoms) necessary to establish an extended HPI. Noting which elements are negative rather than saying “HPI negative” will show your payers the exact work that the physician did gathering the information.

FAQ 3: Calculate E/M Elements for Brief Exam and Procedure

Question: A patient presents to the ED for a tetanus shot. Another physician had already examined her injury — a puncture from a can that she was opening. The ED physician documents a very brief exam of the wound and orders a tetanus shot. Can this visit count as a moderate-risk service, due to the intramuscular injection and the potential for adverse reaction?

Answer: If you refer to the clinical examples section of the CPT^® manual under code 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a problem focused history, a problem focused examination, straightforward medical decision making), one of the samples reads: “Emergency department visit for a patient for tetanus toxoid immunization.” So while your assessment of the moderate risk associated with this scenario may be correct, you should continue to consider low-level E/M services for these situations (usually 99281) if the patient has only a cursory interaction with the ED physician and has been pre-screened by another provider.

If the ED physician is seeing the patient for the first time, evaluating a traumatic injury, and addressing the mechanism and the potential complications, then a higher EM code may be appropriate, depending on the documentation and the medical necessity driving the visit.