ED Coding and Reimbursement Alert

Question: If the emergency department physician treats a patient and admits him, is it correct that we need only two elements of history - the past medical history and either the social or family history? An auditor recently told me that all three elements are required for an admission.
  
Kansas Subscriber
 
Answer: The auditor would only be correct if you are billing for the inpatient admission rather than an ED E/M service. The 1995 documentation guidelines require two of three from the patient's past/family/social history (PFSH) to satisfy the requirements for 99285 (ED visit for the E/M 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), and that requirement is unrelated to whether the patient becomes an inpatient.
 
In the rare circumstance in which the ED physician is the primary admitting attending doctor as well, you wouldn't bill the ED E/M. Instead, you should bill the more comprehensive inpatient admission code, which does require all three elements for PFSH for a comprehensive history.
 
Exception: You will need all three elements if the physician admits the patient to observation and you report the services with code sets 99234-99236 (Observation or inpatient hospital care) or 99218-99220 (Initial observation care). Keep in mind that this requirement is different from the rules for 99285, which only require two of three in this area. While many auditors may use the conservative "three out of three" approach, it is not necessary by Medicare guidelines for the ED E/M codes.