ED Coding and Reimbursement Alert

If indecision about medical decision-making is throwing your E/M reporting for a loop, consult these four helpful documentation hints to simplify your code selections.

1. Ask the physician to list complicating factors. These could include comorbidities, other chronic conditions the patient may have, medications the patient is already taking, or adverse reactions the patient had to previous medications.

For example, if a physician prescribes two or three medications, talks to a consultant, and re-evaluates the patient twice, the case will usually warrant a level four (99284) or five (99285), depending on the risk to the patient and the kind of tests performed. Your key to success here is to make sure the physician documents the case’s complexity -- not just the diagnosis and procedures.

2. Look at the tests and medications the physicians ordered for clues to the extra complexity the physician may not be explaining. Look in the history of present illness and review of systems to determine what the physician is trying to rule out, but also encourage the physician to state what diagnoses he hopes to rule out or confirm.

If a diagnosis is not definitive, make sure your physician has documented pertinent signs and symptoms. For instance, if the patient is stable, look for statements telling you whether she has shown improvement or is worsening and whether the doctor has planned a workup.

3. Don’t code a higher E&M service than the documentation supports. Coders may report 99285 by invoking the acuity caveat when the documentation indicates the patient is in really bad shape. But unless the ED physician has documented that the history or exam is limited due to the patients clinical condition or mental status the coder cannot use the acuity caveat for 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity) simply because the documentation is insufficient to support 99285.

4. Ask for more details if the physician writes something like “labs reviewed.” The patient may have had an adverse reaction to something he received in the emergency department. Likewise, if the physician followed up on the patient’s blood pressure, find out what was wrong with the patient’s blood pressure earlier.