ED Coding and Reimbursement Alert

Here's how to make economic choices with E/M documentation

Elements from the physician's review of systems (ROS) and history of present illness (HPI) documentation can work harder than many coders make them. Here's how to ensure you-re not wasting valuable time querying the physician--or losing reimbursement through downcoding--by using the available information wisely.

Section Categories Aren't Holy

While some coders adhere religiously to drawing ROS elements from the ROS section in the chart and HPI elements from the HPI section, there's no prohibition against mixing and matching. In fact, when you-re short on information from one section, it may behoove you to nab an element from another section to satisfy the E/M level that best represents the physician's work.

For example, if the emergency department physician documents a contributing complaint in the HPI, you can use that information to meet the appropriate number of systems in the ROS--the doctor doesn't need to document the same information in both the HPI and ROS sections.

-According to CMS, where you get the information in the chart means nothing--you should use the entire dictation for your information,- says Kevin Arnold, CPC, medical coding instructor and outpatient coder at Danbury Hospital in Danbury, Conn. -A common mistake among coders is to compartmentalize into the section that the heading puts it into. What we are supposed to do is determine where it belongs by the context of the statement (for example, HPI, ROS, or PE)--the statement will tell you where it belongs.-

Any item can count for both the HPI and the ROS, Arnold says. However, you cannot count it twice for two items within the same category. For instance, you cannot use the same item for -quality- and then -severity- in the HPI.

Beware of Payer Quirks

You-ll find documentation from CMS available on the American College of Emergency Physicians (ACEP) web site at www.acep.org confirming that the doctor doesn't have to list an element twice for you to use it twice. But despite concrete, written confirmation, payers still love this myth. Depending on where you-re located and which carrier you-re billing, you may or may not face difficulty in getting these claims paid.

In Texas, for example, you cannot use a single piece of documentation to receive credit in two different subsections of the E/M service, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Deer Park, Ill. The Texas medical director has stated in no uncertain terms that she gives no credence to the letters written by the Noridian medical director, nor to the one written by CMS in regards to using the same element for HPI and ROS. -While we would like to think that the interpretation of the documentation guidelines is the same across the country, the sad reality is that it is not,- Gilhooly says.

The latest: CMS recently held an open-door forum at which the agency affirmed that carriers can continue to interpret guidelines as they like in regards to the multiple-element issue.

Trump Details With Common Sense

Remember that your goal is to present the most accurate picture of what took place during the ED encounter and report the work the physician did. Even if you have authoritative statements to back up your position to a carrier, what matters most is what makes the best sense.

-The documentation guidelines are just that--guidelines,- says Mason A. Smith, MD, FACEP, chief executive officer of Lynx Medical Systems Inc. -They are not a coding algorithm and should not be considered an entitlement to code a level of service because the minimum criteria for a level are met.-

For example, Mason says, this principle is very clear for the distinction between reporting a level-three E/M and a level-four.

With today's robust documentation processes such as templates and prompted dictation, encounters in the ED frequently meet the -detailed- history and physical exam requirements for 99284, even for more minor complaints. Of note, level three requires an -expanded problem-focused- history and physical, while level four requires a -detailed- history and physical.

-If the documentation guidelines were used as a strict definition of a level four, the average frequency of level four would be 50 percent or higher. Obsessing with issues of the ROS/HPI deflects the coder's attention away from the important judgment issues of what is the value and complexity of the encounter,- Mason says.

Smart move: Critically assess the physician's medical decision-making documentation to give you a solid picture of what kind of service you should report, Mason says.

Following documentation guidelines too much to the letter can obscure your larger understanding of the physician's service. For example, a physician may provide a -complete- review of systems while failing to discuss why he discharged the patient with chest pain.

Remember: While there are three -key elements- that determine a level of E/M service, CPT lists seven components. The crux of the distinction: the nature of the presenting problem (NOPP).

Code 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity) includes the language -usually the presenting problems are of moderate severity.- Code 99284 (-a detailed history, a detailed examination, and medical decision-making of moderate complexity), on the other hand, includes the language -usually the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.-

This distinction is frequently clinical and can be vexing for coders. Keeping open lines of communication with your doctors will facilitate understanding of which presentations the doctors feel are moderate in severity versus those requiring urgent evaluation.