ED Coding and Reimbursement Alert

Question: A patient from a nearby nursing home reports to the ED with a low-grade fever. The patient is chronically demented with bouts of delusion, and unable to provide any information on her own; the patient's caretaker cannot help the patient communicate with the physician either. The physician orders urine tests after an expanded problem focused exam. Test results point to a urinary tract infection (UTI), which the physician diagnoses; the patient is then discharged with a prescription for antibiotics. Can I apply the ED acuity caveat for this scenario?

Tennessee Subscriber

Answer: This is not an ED acuity caveat situation. On the claim, report the following:

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M;

• 599.0 (Urinary tract infection, site non specified) appended to 99283 to represent the patient's UTI; and

• 290.12 (Presenile dementia with delusional features) appended to 99283 to represent the patient's dementia.

Explanation: The ED acuity caveat, which allows coders to 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 some E/M services without the provider documenting a comprehensive history, is not suited for every uncommunicative patient.

If the physician does not perform high-complexity medical decision making (MDM), the physician cannot invoke the caveat. A demented patient with a UTI does not require upper-level MDM, so stick with 99283 for this claim.

Exception: The situation you described does not qualify for the ED acuity exception, but if the history is limited by the patient's dementia, you might be able to apply the Medicare history caveat, which is part of the 1995 documentation guidelines.