ED Coding and Reimbursement Alert
Never Base E/M Code Choice on Condition
Question: Our ED sees a lot of patients with multiple comorbidities, and many of these patients have presented with COVID-19. Can we bill for a higher-level E/M service to reflect these more complicated encounters? New York Subscriber Answer: As with any ED evaluation and management (E/M) service, you’ll establish the level of service based on the history, exam, and medical decision making (MDM). The trick is to not get distracted by outside knowledge of complications and comorbidities. Stick to what’s documented. That’s not to say comorbidities won’t ever move a COVID-19 E/M encounter from one level of service to another, but only the documentation can help you boost a code level, not the complications and comorbidities. For example, if a patient has a history of COPD and asthma, coding J44.- (Other chronic obstructive pulmonary disease) or J45.- (Asthma) for the current encounter is not appropriate unless the provider’s notes for that visit clearly indicate the conditions’ relevance to the projected treatment course. Further, don’t count those problems toward the level of MDM unless the provider “addressed” them. Per CPT® guidelines, “A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.” If a provider’s notes are unclear, request clarification.
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