ED Coding and Reimbursement Alert

Beware: This ED exception has strict documentation requirements.

A patient reports to the ED with a severe illness or injury. Encounter notes indicate that the physician provided a comprehensive exam and high-level medical decision making (MDM) ... but the history documentation is limited.

What do you do? The level five ED acuity caveat, a very specific coding exception, could help you code this service as a 99285 " provided the encounter notes reflect a level-five exam and MDM.

Before using the ED caveat, however, you need to know when you can " and can't " invoke this inception. If you employ the ED caveat improperly, auditors are likely to come beating at your door.

Use these ED caveat do's and don'ts to guide your ED exception coding.

Do Look to Caveat When History's Unobtainable

In basic terms, the ED caveat allows providers to document the history that is reasonably obtainable from a severely ill patient while being excused from meeting the otherwise stringent documentation requirements for 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 ...) The "ED caveat" acknowledges the fact that some patients seen in the ED setting are too acutely ill for the provider to obtain a useful history,

Consider this detailed example from Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass.:

Even though the history was limited, you can report 99285 for this scenario " provided you include the documentation our experts recommend.

The level five acuity caveat differs from the general statement in the Medicare documentation guidelines, which states: "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history."

This allowance within the Documentation Guidelines is typically referred to as the "history caveat" and relates specifically to the history component of the encounter.

Remember: The history caveat does not allow providers to omit documenting history obtained from family, friends, emergency medical services, nursing home records, etc. "However, if the provider makes an honest attempt to obtain history and is unable to do so, then they can still receive full credit for an extended HPI if they document why [history was unobtainable]," explains Lemanski.

Don't Tab the Acuity Caveat for 99281-99284

There are a number of circumstances that could prevent the physician from obtaining a comprehensive history, says Kathy Plato, CPC, director of coding education & credentialing at ebix Inc., headquartered in Wisconsin. Conditions that could prevent comprehensive history collection include "loss of consciousness, dementia, or even language barriers," she says.

While a number of conditions could lead to a caveat situation, there is a single code to which the ED caveat applies: The acuity caveat can only be used on 99285, confirms Plato.

The key to the acuity caveat is in the 99285 descriptor, Plato continues. The 99285 descriptor is the only one in the ED E/M code set that contains this phrase: "requires these three components, within the constraints imposed by the urgency of the patient's clinical condition and mental status."

Translation: There is no acuity caveat exception for any of the other ED E/M codes (99281-99284). "If the physician is unable to obtain this information, but the patient's condition does not qualify for a level five [ED E/M], the caveat may not be used," Plato says.

Do Provide Explanation for Caveat

There are several bits of documentation that you should include on all acuity caveat claims, experts say.

"Documentation of the patient's urgent condition, indicating why the physician was unable to obtain a full history or do a full exam, is required," Plato says.

Best practice: Your practice's documentation system should include a process to remind providers to include the required acuity caveat documentation, Lemanski recommends. "Otherwise, the provider's note should make it clear to a reviewer why the history was not obtainable," he says.

Of note: While the general Medicare documentation guideline exemption applies only to the history component; the language in the 99285 CPT^® descriptor states "...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 ...)."

Translation: The acuity caveat could apply to the physical exam, and potentially the MDM, in addition to the history component. This might occur if the urgency of the presenting condition justifies forgoing the full eight-or-more organ system exam, or diagnostic testing.

For example, if a patient with a gunshot wound to the chest requires immediate transfer to surgery, or expires before the E/M could be completed, you might apply the caveat to the MDM or exam.