ED Coding and Reimbursement Alert

Many emergency department visits could score a level-four or -five E/M code, but some coders report a lower level, meaning less reimbursement. It's time to recapture that lost revenue, and you'll be happy to know that it doesn't take much effort.                                                                                                           

You can ethically optimize your E/M levels by fixing the root of this problem: insufficient history documentation. Obtaining comprehensive documentation is a source of major frustration for ED coders, says Todd Thomas, CPC, CCS-P, president of Thomas & Associates, a company ensuring reimbursement for emergency physicians in Oklahoma City. Insufficient history of present illness (HPI), in particular, is a "very expensive problem."                                            

Use these quick reminders and suggestions to boost history documentation and E/M codes to get the reimbursement you deserve.

HPI: Know What You're Looking For

To move efficiently through the HPI documentation of your E/M claims, you should know what elements you're looking for and the myriad ways physicians can document them. The faster and more accurately you can find these elements, the more money you save.

Here's a short review of the HPI elements, and tips on how to detect them and when to count them toward the history level:

1. Location is the place on the patient's body where the patient is experiencing signs and symptoms. Remember, location doesn't mean the place where the patient was when the injury occurred, but an anatomical geographic description, Thomas says. For example, "left ankle pain" in the chart indicates location, but "while at work" doesn't.

2. Context means what the patient was doing when he or she experienced signs and symptoms. If a patient cuts her hand while sharpening a knife, then sharpening the knife is the context, Thomas says. Another example of context from a chart might be "occurred at work" or "while sitting down," he adds.

3. Quality describes the chief complaint or sign or symptoms. "We're looking for an adjective," Thomas says. So if the patient has a throbbing headache, "throbbing" indicates the quality. Other quality adjectives for this problem could include "pounding," "shooting," "crushing" and "stabbing," he adds.

4. Timing is when the patient experiences the signs and symptoms. If the chart reads "nausea/vomiting in the morning," "in the morning" is your timing, Thomas says. Don't confuse timing and duration, he warns. Timing locates the time of day the problem occurred, and duration describes how long the patient has felt symptoms. If a patient comes into the ED and says, "I've been short of breath since the morning," that statement actually describes duration because the statement reports a time period that hasn't ended. "In the morning" designates an exact time period that is over.

5. Severity describes how bad the patient's problem is. In the physician's history documentation, you will commonly see the severity reported on a scale of 1 to 10 that rates pain, Thomas says. On a handwritten chart, you might see a fraction like "7/10," he explains.

6. Duration is the time duration of the patient's signs and symptoms (explained above under "Timing"). An example of duration is when a patient reports, "I've been vomiting for the last two hours." "The last two hours" is the duration, Thomas states.

7. Modifying factors are the things the patient has done to alleviate the pain from signs or symptoms or the things that make the symptoms worse. For example, chest pain gets worse with exertion and improves with rest. The physician's notes "relieved by" or "exacerbated by" will help you locate these factors, he says. The charts may also explain treatment prior to arrival, for example, "patient has taken Tylenol for fever."

8. Signs and symptoms are any problem(s) in addition to the chief complaint that the patient complains of or denies. The chart might read, "Patient complains of chest pain, also some shortness of breath." Chest pain would be the chief complaint, and shortness of breath would be an associated sign or symptom, Thomas says. Remember to include documentation that discloses when a sign or symptom is not present. "We are not looking at the chart from a clinical mind-set," Thomas reminds. "We're trying to assign a value to the physician's effort," so the physician should get credit for determining the presence and absence of signs and symptoms.

You can't use your triage nurse's documentation alone to get your HPI elements. They must come from physician documentation. Now, under Medicare's requirements, the physician must document the chief complaint and HPI, says Sandra Soerries, CPC, CPC-H, director of healthcare compliance services for Tait Advisory Services in Kansas City, Mo.

Also, remind your physicians to specifically designate the chief complaint. "Without the chief complaint in the medical record there's no medical necessity," Soerries warns. Soerries'coders made laminated cards for ED physicians that highlight what's needed for different levels of E/M codes.

In whatever way seems appropriate for your practice, let your physicians know: Insufficient documentation means a brief instead of an extended HPI, Thomas says, and that, again, is an "expensive problem."

ROS: Help Your Physicians

Insufficient review of systems (ROS) documentation is the physicians'problem, but you can help them by discussing how their documentation translates into payment, Thomas says. Tell your physicians that they need to show documentation of all 14 systems for payers governed by CPT and at least 10 systems for Medicare. Aminimum standard includes denoting pertinent positives and negatives and the statement "all other systems were reviewed and are negative."

To be on the safe side, however, some experts suggest that you advise physicians to document all 14 systems every time. Speak with your physicians about whether they should check each particular system and then confirm each one as negative.

Count toward the ROS those negative statements that describe a particular system, such as "cardiovascular negative" or "denies shortness of breath," Thomas says

PFSH: What Does and Doesn't Count

Your ED will lose money if you incorrectly count the past, family and social history elements that contribute to your E/M level.

Some experts, like Soerries, warn that you can count only the history elements that are relevant to the patient's current problem. Suppose a chart says, "Chicken pox when patient was five." If the patient is presenting for coughing, burning of the lungs and high fever, you can't count that chicken-pox history, Soerries says. But if the chart states that the patient "had chicken pox at five and broke out internally and scarred the lungs," that history is relevant to the patient's problem, and you can count it, she says.

Ultimately, you should speak with your physician about how you should interpret his or her history documentation. In the ED, the patient is always new, and your physician needs to know everything that could potentially contribute to the presenting problems. In that case, almost all past history is relevant, so speak with your physicians about what they document.

On another note, remember that you can count ROS and PFSH information retrieved from ancillary staff such as nurses, the triage staff and even a patient questionnaire, when the physician appropriately references it, Thomas says.

Remember that in the ED, an acuity caveat can sometimes apply to a level-five E/M code. If the patient is too sick to disclose key portions of the HPI or PFSH, or if the urgency of the presenting condition prevents the physician from doing that, you can still consider a high level of service if certain conditions are met, Thomas explains. For example, you must have documentation explaining why the history couldn't be obtained. To read more on the acuity caveat, see the article "Guarantee ED Specialists Their Pay with the Acuity Caveat" in the October 2002 ED Coding Alert