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 [...]