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 [...]