ED Coding and Reimbursement Alert

Question: I have notes in front of me that indicate the ED physician performed a comprehensive examination and high-complexity medical decision making during an E/M service. But the patient was only sporadically conscious during the encounter, and when he was awake, he appeared to be suffering from auditory hallucinations. This made taking the history portion of the E/M virtually impossible for the physician. What E/M code should I assign for this encounter?

Illinois Subscriber

Answer: It may be appropriate to apply the "ED caveat" for this encounter, which would allow you to code a level-five E/M. You can exclude the level of history and/or exam if the patient is unable to communicate due to his condition, or if the urgency of the patient's condition demands immediate treatment. Since the patient was not fully conscious (or cognizant) during your encounter, you may be able to code the service based on the exam and MDM. Just be sure to include detailed documentation of the situation that explains why it was impossible to obtain a comprehensive history.

So if you decide to employ the caveat for this scenario, report 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 the E/M.

Remember to append 780.02 (Alteration of consciousness; transient alteration of awareness) and 780.1 (Hallucinations) to 99285 to represent the patient's symptoms. Further, include a note of explanation from the physician. Something like "Was unable to complete history portion because patient was in and out of consciousness, and showed signs of auditory hallucinations when awake during the entire encounter" should be a sufficient descriptor.

-- Reader Questions and You Be the Coder reviewed by Michael A. Granovsky, MD, CPC, FACEP, president of MRSI, an ED coding and billing company in Woburn, Mass.