ED Coding and Reimbursement Alert

Reader Question:

Artistic Rendering Used Toward E/M Level

Question: Does a drawing (artistic rendering) of a body part in the exam component of the medical record count as an element toward the E/M level? 

Missouri Subscriber  
Answer: There are no limits on the use of graphic information to meet documentation requirements. If the information is contained in a physician-drawn image, treat that information as though it were text. As long as the data are not ambiguous, they can be used.
 
For example, if an ED physician has a drawing of a torso and shades in an area that he or she labels as tender, it is pretty clear what the physician is documenting. However, if the diagram has no descriptors, it becomes difficult to determine the problem. Most trauma centers use a human picture isolating the face and abdomen with specific symbols to illustrate findings such as tenderness, abrasions and lacerations.
 
As always, it is best to use common sense. Ask yourself, Does this make sense to me? or Would it make sense to someone else (an internist, a surgeon, an auditor, a lawyer)? If the answer is yes, use the drawing in the documentation.
 
As always, it is best to ask the carrier in question for a copy of its policy.
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in Revenue Cycle Insider
  • 6 annual AAPC-approved CEUs
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more