ED Coding and Reimbursement Alert

Question: An apparently homeless patient presents to the ED via ambulance unresponsive with a suspected brain aneurysm. The patient, who had no identification on his person, was found by a homeless man who accompanied the patient to the ED in the ambulance. The man said that he "knew the guy a little bit; he had been complaining about his neck and bad headaches lately." The man could not, however, provide more than the patient's first name. Therefore, the physician had almost no history information; she did, however, provide a comprehensive examination and perform high-complexity medical decision making (MDM) before admitting the patient for further neurological services. How do I gauge the level of history for E/M coding purposes?

Answer: This could be an instance in which the ED caveat is appropriate, which allows for gathering history and physical exam within the constraints imposed by the patient's condition if the patient's care (including highcomplexity medical decision making) would otherwise satisfy 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 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 ...) for this patient.

Check 99285 language: The descriptor for 99285 notes that the service requires the key components "within the constraints imposed by the urgency of the patient's condition and/or mental status." It is this language that allows you to employ the ED caveat for 99285.

CPT recognizes that in some urgent medical situations, the physician cannot always obtain a complete history from the patient. Many times, the physician can rely on medical records and/or family members to help obtain information on the patient's medical history. In your case, however, obtaining a comprehensive history was impossible, so the caveat is a possibility.

Important: If you do invoke the ED caveat, make sure you include a physician note indicating that the required history element was unobtainable (UTO), a description of the patient's condition and a description of the situation surrounding the patient. For your claim, a good physician note might be:

"UTO history due to patient's unconsciousness, possible aneurysm. Px had no identification, family members present, to inform on history."