ED Coding and Reimbursement Alert

Coding for patients with life-threatening illnesses and injuries can require less stringent evaluation and management documentation. But the documentation waiver contained in 99285 can raise havoc for E/M coders unless they know how to handle the paradox of documenting the undocumentable.

For a severely ill patient, extenuating circumstances may prevent emergency physicians and staff from collecting the complete data required to submit 99285. The level-five acuity caveat provides a way both to deliver timely treatment and to recover appropriate reimbursement, even if some of the information required by documentation guidelines is missing from the medical record. But the caveat only works if both the physician and coders carefully document why they need it.

CPT defines the highest E/M code, 99285, as Emergency department visit for the evaluation and management of a patient. The acuity - or level-five - caveat waives the requirement for complete documentation for three components normally needed to justify assignment of 99285: comprehensive history, comprehensive examination, and medical decision-making of high complexity.

CMS accepts the CPT principle as long the patient's mental and physical status reasonably prohibits documentation or the patient's conditions are severe enough to present an immediate, life-threatening situation, said Robert Kottman, MD, Alamo Physicians Services Inc., in Universal City, Texas, during a recent EDPMA conference in Bal Harbour, Fla.

According to Dorothy D. Steed, CHCC, CPC-H, CPAR, a Medicare specialist at Northside Hospital in Atlanta, her ED regularly encounters patients whose emergent conditions allow the presenting problem to trump E/M documentation requirements. Because E/M documentation depends on patient participation, incapacitated or limited patients create a documentary hole.

For example, a common clinical scenario seen in the ED is an elderly patient with pneumonia or a UTI with early sepsis who presents by ambulance without any family. Often family and friends are absent, and if the patient doesn't live in the area, it takes at least a day to get contacts, Steed says. The patient has altered mental status, and his evolving sepsis requires prompt clinical attention even as the conditions prevent a complete history and physical from being performed.

To guarantee reimbursement, physicians must document the attempts made to complete undocumented E/M categories by recording why the physical or mental condition of the patient precluded a complete history or physical, says Steve Verno, practice manager with Emergency Medicine Specialists, North Miami Beach, Fla. Verno notes that physicians can help their practices and boost their payments if they carefully document reasons for applying the caveat so that coders have clear signposts. But rest assured, Verno says, with documentation that passes muster, the caveat covers all areas of the history of present illness (HPI), review of systems (ROS) and past, family and social history (PFSH).

Experts strongly recommend that coders check their local carriers for clues as to how they interpret the caveat. Medicare and commercial carriers have different policies for using the patient's condition to document missing information. In addition, some regional Medicare carriers apply the caveat only to the historical component, while others throw in the examination component but not decision-making, Kottman adds.

The moral of this story: Documenting what can't be documented is crucial for reimbursement. When faced with missing information, physicians must thoroughly explain what precluded standard E/M documentation in order to circumvent claim denials. Documentation must always support the waiver.