ED Coding and Reimbursement Alert

Question: How should I code for a patient who presented to the ED with cardiac arrest and died? The physician didn't spend enough time for a critical care code, and he just documented the time of death and discussion with the primary-care physician to sign the death certificate. Our physicians think the severity of the situation overrides the lack of documentation.

Rhode Island Subscriber Answer:  If the chart documentation would support a level-five evaluation and management service "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status," you could invoke the acuity caveat for missing documentation of history and physical exam normally required 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: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity). 

The level-five acuity caveat provides a way both to deliver timely treatment and to recover appropriate reimbursement, even if some of the information required by documentation guidelines is missing from the medical record. Here's the catch: The caveat only works if both the physician and coders document why they need it. 

Keep in mind that when you report 99285, the acuity - or level-five - caveat waives the requirement for complete documentation, including a comprehensive history and/or comprehensive examination.

Otherwise, you should consider reporting 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest]) and any other procedures the physician performed that accurately describe the services provided. In the event that the patient was dead on arrival, many emergency phys-ician groups don't charge for merely pronouncing the patient dead.