ED Coding and Reimbursement Alert

Here's how to make smart choices about HPI, MDM

Diagnostic tests, HPI elements, and radiologic review can all make choosing the correct E/M level difficult in the ED. If you-re having trouble deciding what credit these services should receive, check out this expert advice on tough E/M questions.

Collect Credit for Diagnostic Decisions

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 you document that the physician ordered the test, the patient refused it and why he did so.

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, says Jim Collins, CPC, ACS-CA, CHCC, CEO of the Cardiology Coalition in Matthews, N.C. Physicians frequently recommend a test, but the patient declines for various reasons (for example, financial concerns or reservations about risks).

Give the Physician Credit

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,- says Sherry Wilkerson, RHIT, CCS, CCS-P, manager of coding and compliance for CHAN Healthcare Auditors in St. Louis.

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. The physician urges the patient to go through with the CT scan and documents appropriate clinical and medical legal support for his concerns. Ultimately, the patient still refuses the test.

Even though the patient did not undergo the study, the physician's documentation reflects his higher level of concern, and that should be factored into the medical decision-making.

Don't Dismiss HPI Elements

Question: A patient presents 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 he reported that no activity exacerbates the condition and no associated signs or symptoms exist?

Answer: The physician deserves to receive credit. What you-ve provided is valuable information, which the physician should document.

Ensure Accurate Documentation

Quick tip: Don't let the physician 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 writes, -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,- Collins says.

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, Collins says. Some payers have looked askance at negative HPI factors, but good clinical documentation should help to further support these meaningful elements.

When you add in the documentation -an anatomic description of where the problem is (which should be possible for about every condition), you would firmly establish an extended level of HPI,- he says. 
 
Under the 1995 documentation guidelines, this level of history is necessary for any ED visit of 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history, a detailed examination, and medical decision-making of moderate complexity) and 99285 (... 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).

Account for Image Ordering and Review Separately

Question: The Marshfield Clinic's audit tool awards two points for independently visualizing an image, tracing or specimen (not simply reviewing a report). The tool also awards one point for ordering a diagnostic test. If the physician orders a test (such as an electrocardiogram) and he personally reviews the tracing on the same day, would he be awarded credit for both the order (1 credit) and the personal review (2 credits)?

Answer: Yes. The order and personal review are two separate activities. If the doctor orders the electrocardiogram, she might not get to review it. If she does review it or look at it and makes judgments, then documenting this activity should allow her credit for both ordering and reviewing it (not just reading a report).

Break It Down

You should understand that, when it comes to the audit tool's complexity section, you only need four credits in the data section to achieve a -high- level of medical decision-making, assuming that at least one of the other complexity section elements (diagnoses/treatment options or table of risk) also supports this level of complexity.