ED Coding and Reimbursement Alert

Invoke the CPT^® history caveat if the patient is not able to offer a reliable history

The United States population is aging with over 10,000 new Medicare beneficiaries enrolling every day. And coding for geriatric patients that present to the ED from nursing home settings can be challenging.  These patients often have multiple chronic conditions and obtaining a complete history is difficult.

A recent study published in the Annals of Emergency Medicine showed that there are 4 key elements that providers should pay extra attention to when managing geriatric patients:

1. Disposition changes;
2. Mental health status;
3. Blood pressure readings; and
4. Heart rates.

Small changes or abnormalities in these characteristics in elderly patients can indicate a higher chance for ICU admission shortly after discharge, according to the study. These fluctuations can also point to a possible higher risk of death in these patients.

Take note: It's very important for coders to pay attention to the details while coding for elderly patients as these patients are much more likely than younger patients to have bad outcomes, says Stacie Norris, MBA, CPC, CCS-P Director of Coding Quality Assurance for Zotec Partners in Durham, NC. Coders must learn to factor in this extra level of risk for elderly patients when assessing the level of medical decision making.

For example: An elderly patient with a history of COPD who presents to the ED with a chief complaint of coughing, dyspnea and fever, will usually have a higher level of morbidity and mortality risk than an otherwise healthy 30 year old patient presenting with these same symptoms.

What if the History is Not Complete Enough to Form a Definitive Diagnosis?

When a patient presents to the ED from a nursing home, often times the patient is suffering from some stage of dementia. Dementia is a group of disorders, not a specific disease. Dementia can be caused by a variety of disease processes and conditions such as: Alzheimer's disease, vascular dementia, Lewy body dementia, Parkinson's and traumatic brain injury. If the Emergency Department has access to the detailed clinical cause of the dementia, documenting this will allow the most specific diagnostic coding for the case, Norris explains.

For example: A patient presents to the ED via ambulance from a nursing home after a fall. The patient was complaining of some arm pain at the nursing home, but now is saying she is fine. The ED provider assesses the patient for possible injuries and also assesses the patient's neurological status. The final diagnosis is documented as: 1) right arm sprain and 2) Alzheimer's disease and dementia without behavioral disturbance. The ICD-10 coding for the second diagnosis is: G30.9 (Alzheimer's disease, unspecified) and F02.80 (Dementia in other diseases classified elsewhere without behavioral disturbance).

Provider ICD-10 documentation tip: For patients with dementia, specify with or without behavioral disturbance in your documentation. For patients with Alzheimer's disease, specify early onset, late onset or other specific type of Alzheimer's. These details allow the coder to select a specific ICD-10 code rather than an unspecified code says Norris. She also notes that under category G30 (Alzheimer's disease), there is an instructional note to also code:

• Delirium, if applicable (F05)
• Dementia with behavioral disturbance (F02.81)
• Dementia without behavioral disturbance (F02.80)

It is a fact of life in the ED-setting that many times the ED provider may not have the specific dementia causation documentation available during the patient's stay in the department. As a result, the diagnosis is often documented as just "dementia," which you'll code as F03.90 (Unspecified dementia without behavioral disturbance). You'll also code a diagnosis of "senile dementia" with an F03-- (Unspecified dementia) category code, Norris explains.

Invoking the Acuity Caveat

Another concern that arises when geriatric patients present to the Emergency Department, is the issue of the history waiver. There are two types of waivers that may be used when the documentation requirements for them are met:

1. CPT^® Level 5 Acuity Caveat. The CPT^® Level 5 Acuity Caveat is specific to E/M code 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 CPT^® code definition states that the three key components of the E/M level must be met "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status."

2. Medicare Documentation Guidelines History Waiver. The Medicare History Waiver allows that, "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 that precludes obtaining a history."

Providers should always make an attempt to obtain as much history as possible from others such as family or EMS. Some common examples of appropriate Medicare History Waiver cases include patients with active dementia or confusion, nonverbal patients, or violent patients that will not cooperate with ED personnel, Norris says.

The inability to obtain a comprehensive history or perform a comprehensive exam is a clinical decision based on the judgment of the emergency physician at the bedside. If the patient's condition prevented the emergency physician from performing a comprehensive history, be certain the emergency department record documents the situation.

Caution: As a coder, you shouldn't be expected to review a chart with limited documentation and make the decision that the documentation shortfalls are due to the severity of the patient's presentation. And if the emergency physician doesn't document that the history was limited or unavailable due to the patient's condition, auditors are likely to down code the chart for insufficient history.