ED Coding and Reimbursement Alert

Question: I am confused about the proper use of the acuity caveat. I understood that we can only use it to invoke a level-five E/M, but I've recently heard that we can use it for other E/M codes, such as 99283. Is this correct usage?
       
Kansas Subscriber

Answer: The most direct answer to your question is that the acuity caveat in the description of code 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 exam-ination, and medical decision making of high complexity), which is highlighted in bold print, does only apply to a level five evaluation and management (E/M) code. 
 
However, according to the 1995 documentation guidelines, there is a history caveat that states, "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history." 
 
So if the physician is unable to obtain a history from the patient, but the physical examination, medical decision making, and nature of the presenting problem do not support a 99285, you can justify reporting 99282 (...an expanded problem focused history, an expanded problem focused examination, and medical decision making of low complexity), 99283 (...an expanded problem focused history, an expanded problem focused examination, and medical decision making of moderate complexity) or 99284 (...a detailed history, a detailed examination, and medical decision making of moderate complexity) by using this history caveat and assigning an E/M code based on the examination and medical decision making elements.
 
Tip: Be sure to document the reason why the history could not be obtained.