ED Coding and Reimbursement Alert

One could argue that every heart attack (410.9) that comes into the emergency department justifies a level five (99285) evaluation and management (E/M) code.

Unfortunately, the documentation too often fails to reflect the level of medical decision-making spent on the case. Emergency department (ED) physicians should take the time to thoroughly document the complexity of each case to indicate the level of medical decision-making involved in providing emergency treatment. This will optimize reimbursement and provide backup in case of an audit.

How important is medical decision-making? I think its the primary factor, says Sam Roberts, MD, FACEP, president of Third Coast Emergency Physicians, an ED staffing network in Austin, Texas. Obviously, being able to differentiate between a level three, four and five makes a lot of difference.

Despite rules requiring certain minimums in the documentation for each E/M service level, assigning those levels requires more than just adding up elements of the physical exam and history. Theres interpretation on all levels, says Harriett Yackell, medical records director at Community Health Center, a medical facility with six ED physicians in Coldwater, Mich. If the physician documents that the patient has acute bronchitis (466.0), thats very clear-cut to us. But if the physician documents chest pain (786.5x) or shortness of breath (786.05) but with no confirmed diagnosis, that in itself would be what we code.

Thats where decision-making becomes crucial because documentation can show coders and payers that the case was more complex than it seemed. We try to educate our physicians to document everything they do, Roberts says. Of course, if its a sore throat (462) and they document it as if it was a level five, no matter how much they put down, its still probably a level two (99282).

The reverse also holds true. Even a cardiac arrest (427.5) cant be billed at a high level if the documentation isnt there.

Service level codes reflect the time a doctor spends on a patient, while hospital visit codes reflect the resources used to provide care. For either facility or physician coding, the same case could be reimbursed at either a two or a five depending on the documentation.

Assessing the Medical Decision-Making

Both physician and facility coders normally rely heavily on the doctors documentation to determine what to code. So how do they transform all the information into an E/M service level? Thats where you come down to the art of coding, which requires that the coder have some knowledge about what the medical treatment entails, says Roberts.

HCFA requires certain components from the patient history and review of systems to justify each code level, but thats just the beginning.

If the physician prescribes two or three medications, talks to a consultant, and reevaluates the patient twice, the case might warrant a level four or even a level five, depending on the risk to the patient, the treatments given and the testing performed, Roberts says. The key to success here, both from a coding and a legal standpoint, is to document the complexity of the case, not just the diagnosis and procedures performed.

The most prevalent coding error involving medical decision-making is failure to code every facet of the patient encounter, and the fault usually lies with the doctor, not the coder. We all go through a continuous assessment of our patients and tend to go back through every piece of information weve got every time we get a new piece, Roberts says. But we dont always put down every reassessment. Were lucky if we record the reassessment, consultation and tests. Thats probably good documentation for most of us, but theres more we could do.

Without an understanding of the doctors thought process, even the most objective and conscientious coder cant get the complete picture.

Roberts offers these examples of how different documentation of the same case results in vastly different service levels:

Scenario One: More Information Needed

A 40-year-old man presents to the emergency room with chest pains (786.5). Documentation shows that the doctor:

Takes a history of present illness, learning that the patient has had burning chest pain for two hours, but no nausea (787.02).
Performs a review of systems, emphasizing the chest, abdomen and heart.
Performs the appropriate exam.
Orders an electrocardiogram (EKG) (93000-93010), a chest x-ray (71010-71035), and some cardiac enzyme tests (82550-82554, 83615-83625, 83874 and 84484).
Orders medication, an antacid.
From the test result, learns that the patient has no
cardiac condition, just reflux esophagitis (530.11).
Prescribes Pepcid and instructs the patient to follow up with his doctor.
Coding result: level two, possibly three.

Scenario Two: Complete Documentation

The same 40-year-old man presents with chest pains. More complete documentation shows that the doctor:

Takes 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 got worse when the patient lies down but not when he exercises. The patient also took aspirin and felt no relief.
Takes a past medical, family and social history, learning that the family has no history of cardiac illness but does suffer from gastric ulcers (531), and that the patient is a married nonsmoker who has no history of serious illness.
Performs a review of systems, including eyes, ears, nose, throat, cardiac, gastrointestinal, respiratory, psychiatric, and skin, noting in the gastrointestinal (GI) review that the patient felt no nausea and was not belching (787.3).
Performs the appropriate exam.
Considers that the problem could be reflux esophagitis, a coronary syndrome, musculoskeletal chest pain (786.59) or possibly an anxiety reaction.
Orders an EKG, a chest x-ray, and some cardiac enzyme tests and records the results (normal) in case the payer doesnt get the test reports.
Attempts treatment with an antacid, which gave the patient relief.
Gave patient aspirin in case of a cardiac condition.
Reexamines the patient and determines that the pain
has not returned.
Speaks with a consultant to arrange follow-up with another GI test or an exercise stress test (93015-93018).
Discusses everything with the patient, telling him
that the pain was most likely reflux esophagitis, but
that he cant entirely rule out a cardiac condition. The
ED physician instructs him to follow up with the consultant for his tests.
Coding result: level five.

The second example offers a much more complete picture. With that written record, you can see that the physician was thinking about a lot of different things, Roberts says. The problem is that this takes a lot more time to document. If theyre busy, they tend not to. So they get paid less when theyre busy, unless they really make an effort.

Proactive Steps

Coders should know enough to recognize the gaps in the documentation for scenario one. The information left out of the record could justify an increase in both the physician and facility service level, but its often hard to resurrect that data after the fact. How can coders do that? Yackell asks. Our ER [emergency room] guys may see 100 patients on a 12-hour shift. Unless theres something specific about the case that stands out in their mind, theyre going only by the notes.

The best thing coders can do in this instance is offer feedback individually, Roberts says. When they see a pattern of underdocumenting on cases that probably deserve a higher level, then they can get back with the physicians, saying, You did an EKG, so you must have been concerned with cardiac. But you dont mention enough things in here to demonstrate that you spent much time on it.

Roberts believes about 20 percent of physicians will respond very well to feedback, while 20 percent will ignore it entirely. The remaining 60 percent will respond in proportion to the quality and frequency of feedback they receive. We all tend to have a pattern of extinction if we do well, but if we dont get more feedback, we tend to slough off.