ED Coding and Reimbursement Alert

Nugget: ED physicians and staff should be encouraged to document history with: history of present illness, past family and social history, and review of systems portion of the patient exam to increase the level of decision-making needed to optimize reimbursement.

The new rules that instruct facility coders to record signs and symptoms on the UB-92 form have opened the door to more accurate reflection of hospital services. This rule will require coders to make even more use of the patient history. Since the history portion of the patient encounter is the only place where a coder can find information about symptoms after the fact, it becomes increasingly important to ensure that the history portion of the exam is taken and used correctly for optimum billing purposes.

For a problem-focused visit, often coded at 99281 (DEF) or 99282 (DEF), the history of present illness (HPI) needs to include the chief complaint, symptoms, and some brief information about the onset of the problem, according to Sue Mote, CPC, director of reimbursement and operations consulting at the Healthcare Practice Enhancement Network in Los Angeles. You only need to meet so many components. If it is a complex visit or a new patient, it will generally include everything. It starts to become more complicated depending on the level of visit.

High-level visits, such as those that might be coded 99284 or 99285, require much more information. In addition to the chief complaint and symptoms, these visits might require a more extensive HPI, as well as information on a past, family and social history (PFSH), and a more complete review of systems (ROS). In emergency medicine, often the most important part of what doctors do for the patient depends on that history, according to Patrick ONeal, MD, emergency department medical director at Dekalb Medical Center in Decatur, Ga. Were taught early in medical training that the majority of diagnoses can be made from the physical and the history without a bunch of tests. And of the two, the history is infinitely more valuable than the physical in most cases.

Document to Boost Decision-making Level

Unfortunately, many doctors do not recognize the value of documenting history, leaving coders without information needed to effectively code claims, Mote notes. Coders may have in their minds the fact that a code could have been used, but the documentation does not support it.

All the history in the world is not enough to justify a high-level claim when the decision-making is not difficult. But if you have a complex case, with complex decision-making, and you skip the history, you cannot support the high-level visit.

The only solution to this problem is alerting doctors about gaps in their documentation. The physician may be thinking, But my patients are really sick. Why am I not seeing more level fours and level fives? Mote says. You have got to give them an analysis based on the exam and medical decision-making. Where you could have coded a 99284, you were forced to code a 99283 because the doctor did not document the review of systems.

Detail the History

The past history of illness, which may be completed on a form filled out by the patient, tells the coder whether a patient has been hospitalized or had surgery in the past, along with other past, personal health information about the patient. Under the new signs and symptoms rule, a coder may be able to use this document to justify tests the doctor ordered, particularly if the patient visited the hospital for the same complaint in the past.

Mote said a PFSH should include questions relevant to the patients condition as well as family medical histories that may relate to the patients current problem. She said that clinicians often skip the family and social history altogether, which is a mistake. This information can help coders immensely, ONeal asserts, especially when patients present symptoms like chest pains (786.5x), which may require a battery of tests to determine whether they suffer from a heart attack (410.xx series) or indigestion (536.8). Very often, if we can code the system complex, rather than the final result of the evaluation, it demonstrates to the payer what weve done for the patient, asserts ONeal.

A physician or facility might be better able to justify ordering extensive testing on a patient who comes to the ED with chest pains (786.5x) if the patients father died of heart disease or cardiac arrest.

Dont Overlook the ROS

The ROS, a list of questions about certain symptoms or conditions, often causes problems for coders, Mote notes. With most physicians, this is one of the weakest areas. They often jump to the exam, where they test for some things they might have asked about. Often, doctors think their exam is hitting the necessary ROS components, but that is not the case.

Mote adds, If youre performing a gastrointestinal exam and the patient has stomach tenderness, that may qualify as a component in the exam, but it doesnt qualify for ROS.

This overlap of the exam and the ROS often confuses coders, because while the doctor might come up with important information in the exam, if its not part of the verbal ROS, coders cannot use it as part of the history. Physician coders deal with this issue all the time, and now that facilities are being told to code signs and symptoms, ED coders will encounter the same problems. Basically, if the history is missing, then it completely alters the level of coding that you can bill, Mote said.

ONeal says that many claims are reimbursed differently based on whether the condition is acute, subacute, or chronic. These are things you most often obtain from the history. The onset of the complaint may also be very important to record, in terms of understanding that it was or was not an emergency condition at the time the patient presented.

When the patient has a chronic condition however, coders should be careful to identify the acute exacerbation of the chronic condition that brings the patient to the ED. In other words, code signs and symptoms based on what is different about the problem now.

Patient history can also tell coders about degrees or gradations of symptoms. If the patient is presenting based on pain, we must know the severity, he said. Severity determines, in some degree, what reimbursement is going to be. Mild discomfort in the ear may be considered a condition that should be treated in a physicians office rather than the ED, and the payer may deny payment if described as a mild earache (388.70). But if its severe pain with a high fever (780.6), the payer might be more likely to reimburse.