ED Coding and Reimbursement Alert

Question: Is there such thing as an acuity caveat for medical decision-making (MDM)? A patient presented with three seizures that day for unknown reasons and left against medical advice to drive himself home. We had an auditor "caveat" this case to a level five. Is this correct?
         
Colorado Subscriber
 
Answer: While no specific acuity caveat exists for MDM, the Medicare documentation guidelines do state that the physician's documentation should reflect why the doctor couldn't obtain a complete history. Logically, these guidelines would then allow for an incomplete history if there is a plausible reason - for example, cerebrovascular accidents, dementia and encephalopathy. These guidelines aren't specific to a given level of E/M code.
 
Within the definition of 99285 (Emergency department visit for the evaluation and management 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), the phrase "within the constraints of the patient's condition" extends to history, physical examination, and MDM.
 
Though it is technically allowable to invoke this caveat for the MDM portion of the code, there would need to be medical necessity for the lack of MDM documentation, and in the scenario you present above, invoking the caveat seems like a stretch.
 
For example, for a patient with a rupturing aortic aneurysm who gets rushed to the operating room, it's understandable that the physician may not be able to obtain a comprehensive history and eight physical exam elements, but he could still document the MDM as you complete the chart documentation. The important part is that the ED physician communicate and document the high risk.
 
Remember: Even at the highest level of complexity, documentation guidelines require that only two of the three categories of MDM must meet or exceed the assigned level. The "urgency of a presenting problem" could easily limit the amount and complexity of data the physician reviewed, but would not have an impact on the risk category and less so on the number of possible diagnosis and management options considered. Most payers accept the acuity caveat for history, and you could make the argument that it applies to the physical exam, but be prepared to defend your rationale for applying it to MDM.