ED Coding and Reimbursement Alert

Question: Our ED physician performed an extensive exam on a patient in cardiac arrest but failed to fulfill documentation requirements in the history portion of the E/M. I'm a multispecialty coder and know E/M guidelines, but the physician insists on this being a level-five visit. Will I get in trouble for coding a visit with a higher-level E/M code even if all criteria are not met?

Oregon Subscriber

Answer: No, you should not get in trouble for coding this as a level five. Unlike all other E/M service levels, which require that all three key components (history, exam, and medical decision-making) be fulfilled and documented, ED E/M code 99285 has a special exemption.

When the nature of the presenting problem is severe enough to interfere with any of the three key components, ED physicians may invoke the "acuity caveat" or the "level-five caveat." This provides a clinically based exemption from the three key components and is outlined in the introductory material for 99285: "Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status."

To qualify this for the exemption, some payers want a copy of the documentation sent along with the claim indicating the reasons why the history and/or exam were not complete. A note in each of the three history sections must state how the available history was taken and where the information came from. When a physician is unable to obtain the requisite history when a patient is unconscious, for instance he or she must clearly state why the missing components were unobtainable.

Many ED coders believe they can justifiably report 99285 when a seriously ill patient ends up being admitted before a comprehensive H&P can be performed. But, if the chart documentation doesn't support the urgency of the presenting problem that precluded performing and documenting these elements, you can't bill it. Plus, you will red-flag payers if you report these codes with the caveat too frequently.

Some payers are more flexible than others when it comes to coding level-five ED E/M visits. Check with your carrier and get its level-five caveat guidelines in writing.

Note: For more information on reporting level-five visits, see "Correctly Apply 99285 Acuity Caveat to Optimize E/M Coding" in the January 1999 issue of ED Coding Alert.