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ED Coding and Reimbursement Alert

Identify Missing Medical Decision-Making Components

Published on Sat Jan 17, 2004

2 sample charts tell you when you need to get more information

Check out the differences between these charts to find out when you should request crucial information that could lead to certain assignment of the correct E/M code.

Scenario #1: The Bare Minimum
 
A 40-year-old man presents to the emergency room with chest pains (786.5x). The documentation shows that the physician completed the following services:

 

  •  Took a history of present illness and learns that the patient has had burning chest pain for two hours, but no nausea (787.02).
     
  •  Performed a review of systems, emphasizing the chest, abdomen and heart.
     
  •  Performed the appropriate exam.
     
  •  Ordered an electrocardiogram (93000-93010), a chest x-ray (71010-71035), and cardiac enzyme tests (82550-82554, 83615-83625, 83874 and 84484).
     
  •  Ordered medication - an antacid.
     
  •  From the test results, learned that the patient does not have a cardiac condition, just reflux esophagitis (530.11).
     
  •  Prescribed Pepcid and instructs the patient to follow up with his doctor.
     
    The lack of specificity the doctor gives you would force you to code this case as a level-two E/M service (99282), when, in fact, you could have reported a level-three service had the physician documented properly.

    Scenario #2: The Whole Shebang
     
    The same 40-year-old man presents with chest pains. With complete documentation, you know that the doctor did the following:

     

  •  Took a complete history of present illness, learning that the patient has had burning chest pain for two hours, but no nausea or sweating (780.8), and that the pain gets worse when the patient lies down but not when he exercises. The patient also took aspirin and felt no relief.
     
  •  Took a past medical, family and social history, learning that the family has no history of cardiac illness but does have gastric ulcers (531.x), and that the patient is a married nonsmoker who has no history of serious illness.
     
  •  Performed a review of systems, including eyes, ears, nose, throat, cardiac, gastrointestinal, respiratory, psychiatric, and skin, noting in the gastrointestinal review that the patient feels no nausea and was not belching (787.3). He also records that all other systems are negative.
     
  •  Performed the appropriate exam of at least eight of the organ systems.
     
  •  Considered that the problem could be reflux esophagitis, a coronary syndrome, musculoskeletal chest pain (786.59), or possibly an anxiety reaction.
     
  •  Ordered an EKG, a chest x-ray, and some cardiac enzyme tests and recorded the results (normal) in case the payer doesn't get the test reports.
     
  •  Attempted treatment with an antacid, which gave the patient relief.
     
  •  Gave patient aspirin in case of a cardiac condition.
     
  •  Re-examined the patient and determines that the pain has not returned.
     
  •  Spoke with a consultant to arrange follow-up with another GI test or an exercise stress test (93015-93018).
     
  •  Discussed everything with the patient, telling him that the pain was most likely reflux esophagitis, but that he couldn't entirely rule out a cardiac condition. Instructed him to follow up with the consultant for his tests.
     
    In this case, you'd be justified in assigning a level-five E/M code (99285) because you have documentation to support the complexity of the doctor's decisions.
     
    The information left out of the record could justify an increase in both the physician and facility service level, but it's often hard to resurrect that data after the fact.
     
    The best thing you can do in this instance is offer feedback individually, so when you find patterns of under-documenting for certain kinds of cases, don't be afraid to tell the physician what you need to see. For example, if a physician repeatedly underdocuments when he performs EKGs, let him know that despite your knowledge that a cardiac problem means he spent a lot of time on the patient, he didn't write that down.
     
    A pattern of underdocumenting can cost your practice loads of reimbursement - for example, if you report a level-two (99282) when the actual work warrants a level-four (99284), you lose about $75 each time.

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