ED Coding and Reimbursement Alert

ED physicians who dictate charts often struggle to meet HCFAs evaluation and management (E/M) documentation requirements because they usually miss critical elements that support correct coding. Inadequate documentation is the main reason EDs consistently lose out financially in areas such as critical care (99291, 99292), conscious sedation (99141, 99142), foreign body removals (10120*, 10121) and E/M (99281-99285).

Detailed, accurate charting is critical for coding E/M to the highest level. Its also the only way to reflect accurately the physicians efforts an important part of HCFAs E/M level documentation requirements. Heres a costly example: An ED physician spends hours and employs every tool available to save a patients life. After reviewing the documentation, the coder rates the event as an E/M level one (99281). Life-saving, level one! Ask the coder the reason and youll hear something like, The documentations review of systems (ROS) missed several items. If it had been complete, I could have coded the encounter a level five.

Sometimes physicians forget to document elements such as family history and social history, which are difficult to think about in an emergency situation, but are very important when youre coding later on, explains Michele Tabbone, billing/coding coordinator for emergency services at OSF St. Francis Medical Center, a level I trauma center with an ED of 22 attending physicians and 18 residents, in Peoria, Ill. However, the template tells the physician, This is important. This is information I need to code this procedure appropriately.

Templates are also invaluable for coders with little or no clinical background. You can systematically go down the chart and count your ROS when determining your level, Tabbone says. This is a critical area because the number of systems a physician reviews affects directly the E/M code level. In short, template charts prompt for required details and organize documentation of the
patient encounter.

Make Sure Templates Hold Up Under Scrutiny

HCFA considers templates a viable form of documentation. Coders like templates because HCFAs reporting requirements can be incorporated in chart templates, giving physicians what they need to meet each level of service. Templates can be a great teaching tool as well as a prompt, says Bart Hershfield, MD, FACEP, reimbursement committee chairman of the West Virginia chapter of the American College of Emergency Physicians.

The documentation in a template chart will also weather the challenges of an internal or external audit as well as hold up in court. The validity of the documentation that templates contain cant be challenged any more than that of handwritten or dictated charts, Hershfield says.

Even though dictation has been the industry standard for many years, it produces inadequate or incomplete charts, says John Turner, MD, PhD, medical director for documentation and coding for healthcare financial services at TeamHealth, an ED staffing firm in Knoxville, Tenn.

The differentiator is prompting. Heres how it works: When a patient presents with unspecified chest pain (786.5), the ED physician must determine whether the person is in cardiac arrest (427.5) or just suffering from indigestion (536.8). A complete exam leads to heartburn as the final diagnosis. Even the heartburn diagnosis can rate a higher-level code if and this is the big if the physicians documentation demonstrates the extensive work it took to determine the patients condition.

Templates indicate which elements of history, exam and medical decision-making have been met and prompts the physician to complete or to provide missing documentation. For example, during the course of taking a history of past illness, the chart in that section asks not only for a description of the condition but for a documentation detail the physician might forget the duration of the symptoms.

Review Template Capabilities

Many groups are already using off-the-shelf template charts successfully. Customizing your own charts might be another option, but be forewarned: This is a massive undertaking. Whichever route you take, you must examine some important issues.

Physician and coder needs: Charting has two basic requirements: recording data and extracting data, Turner says. If you dont consider the needs of the coding staff, you might select a template physicians love, but coders find inadequate.

Inserting text: You need to choose a template that allows the physician to insert text because, as Turner asks, If the entire chart is checks and boxes, how can you tell one patient from another? And, Medicare advises against cloning charts. Payers become suspicious when all the completed templates look exactly the same. A template with free space in the history and exam sections of each chart allows you to differentiate patients. Youll be able to create unique case histories even though patients present with the same injury.

The number of templates in a system: Systems offer from 20 to 400 templates. Logically, the more templates you have the more specific symptom-based information youll provide. However, too many could be overwhelming, particularly for staff.

Template specifics: Examine templates closely to make sure they provide the information that is unique to your practice and coding requirements. For example, check the type of related procedure information the template includes. If youre using a musculoskeletal template, does it include related information about splinting or reductions and dislocations? If the template lacks this information, the documentation will as well.

Its also important to have templates that overlap, that is, several different presenting symptoms could lead to one diagnosis. For example, patients with cardiovascular complaints could have other related complaints such as shortness of breath (786.05) and abdominal pain (789.0x). The templates associated with these conditions all should lead the physician to cardiovascular and to respiratory and gastrointestinal conditions. This overlap ensures proper application of ICD-9 coding, which supports the level
of medical decision-making that, in turn, supports
E/M levels.

Consider the Issues Before Choosing a System

Cost: Most template systems are based on the number of patient visits and generally cost between $1 and $2 per visit. Therefore, an ED facility that has 30,000 patient visits a year can incur annual costs of $30,000 to $60,000. Vendor costs usually decrease after the first year and, consequently, so should yours. Make sure the cost of the template package includes training, site visits, customization options, and ongoing technical support.

Before purchasing a system you should compare the cost of the template package and its average cost per patient visit with the cost of dictated records for the same number of visits, Turner explains. An average dictated chart costs between $6.50 and $7.50 across the country.

Education: Physicians and staff should know up front that it might take three months to become familiar with templates. Physicians will need formal training whether you choose a vendor-provided template or design your own. Training should cover issues such as physicians option to dictate.

We expect physicians to use the templates 99 percent of the time, Tabbone says, but they always have the option to dictate, if necessary. For example, OSF St. Francis physicians can opt to dictate in situations they feel might involve the police (e.g., sexual abuse and assault) and in which a template would obviously be inadequate (e.g., massive trauma).

Training ancillary staff is equally important, Turner says. Inadequately trained nursing, registration and/or medical-record staff can nullify any advantage the template offers.

Advantages: Hershfield provides a ready list of template advantages. The documentation is more legible than handwriting; its immediately available (no transcription delay); and, because templates all have the same layout, attending physicians know where to look for the information they need, he says.

Internal audits: Templates allow you to use time previously spent deciphering documentation or dictation to focus on implementing internal audits that will help physicians who consistently miss critical information in their documentation. Tabbone says, You can pull a chart and explain, Because of this documentation we were only able to code an E/M level two (99282) for the physician fee, but with the nurses additional documentation, we could have coded a level five (99285) for the facility fee.

Turner says that as part of the education process
each physician in his group receives these downcoded charts along with individual downcoded rates. Turner says, We give them the results and the rationale. For example, Last month 8 percent of your charts had to be downcoded because your documentation was incomplete. You missed two or three elements, so we had to code the service at a level three (99283) instead of a level five (99285).