ED Coding and Reimbursement Alert

Question: Does the ED level-five caveat apply to the physical exam as well as the history? Must the physician state unable to obtain or due to the patients condition the only organ systems examined were those pertaining to critical care? Can the level-five caveat be inferred based on the patients condition or present problem?

Cheryl Grossman
Phoenix

Answer: According to CPT descriptors, the level-five caveat (limited documentation due to the condition of the patient) applies to all key elements of ED E/M levels when documented appropriately. Physicians must: 1) document which areas are incomplete, and 2) clearly state the reason(s) why. The caveat is not applied unless both requirements are met.

Some payers dispute that the level-five caveat can be applied to the exam, but CPT guidelines clearly allow it. A comprehensive physical exam (eight or more organ systems) can be performed on an unconscious or intubated patient. To invoke the caveat for the physical exam, the physician would need to document clearly that a comprehensive exam was not performed due to constraints imposed by the urgency of the patients clinical condition and/or mental status.

The CPT reference applies to medical decision-making as well. Practical use, however, indicates that the patient requiring such a comprehensive service would qualify for a 99285 (emergency department visit for the evaluation and management of a patient ).

Payers have used many arguments to avoid this protection given to emergency service code 99285. The physicians documentation detailing the patients inability to provide information or the clinical circumstances that dictated limiting the exam is crucial. History is the most common limitation, followed by review of systems. Occasionally the examination is limited to critical areas.

Note that critical care has no documentation requirement other than time (99291, critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). Some coders therefore view 99285 as critical care that takes less than 30 minutes.