ED Coding and Reimbursement Alert

Question: If a patient comes to the ED in critical condition and is not able to give a history, can we apply a caveat? Does that caveat also apply to physical exam or does the doctor need to perform and document a physical exam?

West Virginia Subscriber

Answer: If the patient qualifies for critical care, code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) does not have the typical E/M code requirements of history, physical exam, and medical decision making. As such, the typical history and physical exam required elements (HPI, ROS etc.) are not in place; rather, the documentation must support that the patient was critically ill and the time requirements for 99291 were met.

If however the time thresholds for critical care are not met but the urgency of the patient's clinical condition and/or mental status make obtaining the required H&P elements for code 99285 (comprehensive history and exam), you can invoke the ED acuity caveat as long as you have documentation of the reasons why aspects of your history and physical exam were unobtainable. Reasons such as the patient being unconscious, intubated, becoming unstable or requiring urgent immediate treatment are common in the ED setting.