ED Coding and Reimbursement Alert

Nugget: Emergency departments will gain reimbursement for diagnostic services by coding signs and symptoms along with the final diagnosis. This new rule will help justify medical necessity.

Understanding the prudent layperson standard is crucial when working in an emergency room. Medicare and many insurance payers follow this federal law, which says that the patient determines the need for the visit. If the patient feels that his condition necessitates an emergency visit, then its an emergency, says Caral Edelberg, CPC, CCS-P, president of Medical Management Resources, a training and consulting firm in Jacksonville, Fla.

Although the law requires that facilities conduct whatever tests are necessary to either determine or rule out an emergency condition, neither Medicare nor private payers are obligated to reimburse for those tests, she explains. But a new rule, set forth on April 1, 2000, by the Cooperating Parties Group, which includes Heath Care Financing Administration (HCFA), and the American Hospital Association (AHA), instructs facility coders to use Field 76 of the UB-92 form to indicate the reason for the visit (chief complaint, signs and symptoms). As of that date, facilities are required to code the reason for the visit as manifested by the chief complaint, signs and symptoms on the UB-92 claim form along with the final diagnosis.

Since hospital coders have been told for years not to code signs and symptoms, most will be unfamiliar with the new methodology. In the past, they would have been penalized for coding symptoms, says Jack Turner, MD, of Team Health in Knoxville, Tenn., because coding signs and symptoms was not a facility service compliant with AHA guidelines.

This practice held true even if an insurance company indicated that it would pay based on signs and symptoms codes, Edelberg claims. Coders who follow the old guidelines can cause facilities some serious revenue loss.

The coding changes will be simple, because coders will use the same CPT and ICD-9 codes they currently employ. Most of the difference stems from the change in thinking required to override years of training. Its not a difficult thing to add these codes, but theyre going to have to think a little differently to do it, Edelberg said.

She hopes that as Medicare starts to use signs and symptoms for reimbursement, other carriers will look at Field 76 of the UB-92. Its just going to be a matter of wait and see.

Understanding the New Regulations

These new rules however, do not replace the AHAs outpatient coding guidelines that do not permit coding of signs and symptoms if a definitive diagnosis is confirmed. In most cases, if you go with a chronic or less acute diagnosis complaint, you may not meet the medical necessity requirement for many of the tests or services, Edelberg said.

Hospital outpatient coding rules break down because they do not recognize that work is done based on signs and symptoms. By using the final, definitive diagnosis determined after all the diagnostic studies, you end up generating, in many cases, a medical denial. Its a catch 22. We have to see these people and conduct screening exams based on their undiagnosed conditions, but then the carrier says they did not have a medical emergency, so you should not have treated them.

Will the new rules fix this problem? Not necessarily, though they are a good first step. Many hospitals are audited according to AHA guidelines, and the organization has not changed the official requirements, despite its involvement in the development of the recent regulations. In addition, just because Medicare asks for the information does not guarantee that the government insurer will reimburse it, and other payers are not obligated to pay for it, either.

But we are hoping that as these guidelines become more accepted by different payers, they will start looking for the reason for the visit rather than the diagnosis, Edelberg said.

How to Code Signs and Symptoms

When Medicare reimburses for service provided, theyre interested in the diagnosis, according to Turner. But I believe theyre even more interested in the reason the person came seeking medical care in the first place. This gets into the area of medical necessity.

Turner cites as an example a patient who comes to the emergency department (ED) with chest pains. The physician orders a number of common tests, including an EKG (93000-93010), chest x-ray (71010-71035), and cardiac enzymes (82550-82554, 83615-83625, 83874 and 84484) and the patient is eventually diagnosed with acute gastritis (535.xx series). Under this fairly frequent circumstance, the hospital is bound only to report the diagnosis, gastritis, which is not considered sufficient to justify paying for the tests.

Under the new rule, insurers might see the code for gastritis as the diagnosis, but by coding signs and symptoms, the coder could record other possible diagnoses indicated by chest pains. If you also code the symptom of chest pain (786.5x), that indicates the medical necessity for the tests you ordered, Turner said. By not recording the symptoms, you understate the risk of the problem.

How to Apply the Rules

Signs and symptoms become important when they indicate a higher level of acuity than the final diagnosis, Edelberg says. She believes that coders should be required to code the highest level of acuity according to the presentation.

Certain payers will reimburse only if the ICD-9 diagnosis codes are included on their list of acceptable reasons for ordering a procedure. Therefore, if you can include the signs and symptoms of the presenting problem, it more realistically reflects the reason the patient came and hopefully should then support reimbursement, Turner said.

Signs and symptoms allow facilities and doctors to tell insurers why they ordered tests. If a patient comes in with a headache, insurers are not likely to pay for much diagnostic work. But I could be worried about a hemorrhage or a tumor, or something else that I have to make a diagnosis on, Turner says. Basically, in the area of diagnosis, more is better. As long as it is appropriate and directly relates to the problems, they should try to include as many as they can. Heres an example:

A patient has severe exacerbation of chronic obstructive pulmonary disease (491.21). Turner recommends also coding dyspnea (786.05) and hypoxia (799.0) in the diagnosis. Another potential appropriate diagnosis might be respiratory failure (518.81).

He recalls a situation in which an ED physician treated a patient with acute gastritis (535.00) with the symptom of nausea and vomiting (787.01). The hospital sent a bill with gastritis as the diagnosis, and the claim was denied. When the physician group resubmitted the claim reporting both the diagnosis and the symptoms of nausea and vomiting, they were paid. By including the signs and symptoms code, it clicked into whatever algorithm or list the insurer had for coding, and they paid for it.

Identify Patient Complaint

While the actual codes will be familiar to ED coders and clinicians, using signs and symptoms will require detailed documentation. Physicians and nursing staff have to try to get as much of the patients own words of complaint in the records as possible so that coders can code it appropriately, Edelberg asserts. Very few patients come into the ED and say, I feel diaphoretic. They say, I feel dizzy and clammy and short of breath. Im really weak.

How can facilities better gather patient information? There is not one simple solution. Some facilities will send patients to a triage nurse, then to a registrar, then to the doctor, and all three will ask questions about the patients symptoms and history. Coders can take information from anywhere on the chart, from all people, Edelberg notes. If everyone who records patient information takes good notes and uses the patients words, coders should not have any trouble with coding signs and symptoms.

Document Patient History

The emergency department wants to establish the acuity of the problem, and its important for both the clinical staff and coders to know whether the symptoms are an acute exacerbation of a chronic problem, or something entirely new to the patient. The more information you can get in the patients own words, the better. Those words can provide the coder with knowledge needed to effectively code the claim. The doctor can always convert the patients statement into more clinical language when he starts reviewing the diagnostic test results during performance of the history of present illness (HPI) or physical examination.

This renewed need for detailed discussion of symptoms casts some doubt on the wisdom of using preprinted diagnosis forms, Edelberg says. They cannot cover everything. Do not try to oversimplify this and come up with a list of signs and symptoms and have the doctors or nurses check this off. Edelberg hopes that as Medicare starts to use signs and symptoms for reimbursement of diagnostic tests and other services, other third-party carriers will look at Field 76 of the UB-92 and reimburse as well.