ED Coding and Reimbursement Alert

Question: For a patient who recently presented to the ED with GI bleeding and anemia, the HPI, ROS, PFSH, and MDM all point to a level five. However, on the exam portion of the chart, the doctor only marked "nursing assessment reviewed, vitals reviewed, general appearance - moderate, and skin - pallor." I see only two physical exam areas here. I can't decide whether to downcode this to a level three and send it to the physician for educational purposes, or send it back to ask about additional exam areas. Which is best?


Idaho Subscriber

Answer: Clearly, the physician has not met the level-five physical exam threshold in this scenario. Depending on how much time elapsed between the patient encounter and the coding question to the physician, you would be appropriate in asking for clarification of a chart.
 
Tip: Each group should have a protocol in place for how long a time gap is acceptable for querying. Anything over two weeks could arouse suspicion from an auditor. Most experts believe you should never send charts back solely for additional documentation to justify higher coding - so if that is the case here, coding the chart based on current documentation and sending the chart back for educational purposes seems prudent.