ED Coding and Reimbursement Alert
The 1997 Guidelines Can Prove Helpful
Question: A patient came to the ED with a foreign body in his eye. The emergency physician documented fluorescein dye, Wood's lamp and slit lamp exam. Documentation also includes several attempts to remove the foreign body with no success. The physical exam showed a severely infected sclera as well as an abrasion. The patient was discharged with two RX and sent to the eye-care center where the foreign body was removed. Does the physical exam support a level-three E/M code for Medicare even though no other body areas or organ systems were examined? Is the extensive exam of the eye enough to support that level of service? Oregon Subscriber Answer: Yes, the 1997 Medicare guidelines do support a level-three assignment for the general information you've provided regarding documentation.
The usually unfavorable 1997 guidelines fit the case better than the 1995 guidelines. According to 1995 Medicare guidelines, the E/M required points for a level three must total 1-3 for HPI, 0 for PFSH, 1-2 for ROS, and 2-4 for PE. Note that you have 2-4 points for the physical exam.
According to the 1997 guidelines, the eye single-system physical exam point distribution indicates a fairly thorough exam of the ocular area. For an expanded problem-focused eye exam required for a level three you need at least six bulleted elements documented. For a list of recognized bullets, see the CMS 1997 documentation guidelines, which are available on both the CMS and American College of Emergency Physicians Web sites.
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