ED Coding and Reimbursement Alert

 

ED coders have long argued whether an organ system may be counted in both the history of present illness (HPI) and the review of systems (ROS) portion of emergency department E/M services. Both are components of the history-taking key element, with the HPI covering the development of symptoms that caused the patient to come into the ED, and the ROS an inventory of body systems identifying additional signs and symptoms that the patient is experiencing or has experienced. 
 
For example, a patient arrives at the ED with upper respiratory infection symptoms. When recording the HPI, the physician writes a single note stating that the patient's cough is not productive and that her throat is sore. When faced with this type of documentation, coders wonder if CPT and CMS view the information as restricted to HPI, or if it can also represent a review of the cardiovascular and ENT systems. Further, ED coders question if this information must be listed twice in the medical record before it can be regarded as meeting requirements of both the HPI and ROS.
 
Those who contend the system may not be counted twice believe that doing so represents "double dipping" and pads the service to rationalize a higher-paying code. Conversely, other ED coders believe it is justified, and say those who don't count it twice are downcoding and therefore receiving less reimbursement than they ethically deserve.
 
"This discussion has taken on added significance as documentation for E/M services has come under greater Medicare scrutiny for fraud and abuse," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "On one hand, ED physician practices want to be paid for the level of service they provide and document. On the other hand, they are afraid of drawing attention that may prompt an audit."

According to Mason Smith, MD, FACEP, chair of the American College of Emergency Physicians (ACEP) reimbursement committee for the past four years and CEO of Lynx Medical Systems, a facility and physician coding and billing service based in Bellevue, Wash., it is perfectly acceptable for a single symptom related to any system to be applied to both the HPI and the ROS.
 
In fact, Smith requested and received written confirmation from both his local Medicare carrier (Transamerica Occidental) and the Department of Health and Human Services several years ago. In his request, Smith asked if "a single statement may be used in both areas, negating the need for the physician to repeat him- or herself. In addition, if a notation is made in the HPI section, it is logical that the system relating to the HPI question was reviewed and should be given credit in the ROS. For example, in documenting an ED encounter for a patient presenting with abdominal pain: documentation of the patient's nausea could be used as an 'associated signs and symptoms' for credit in the HPI section and also in 'gastrointestinal' for credit in the ROS section." Smith received a response from both entities confirming that he is correct and stating that it is not necessary to mention an item of history twice to meet the documentation guideline requirement for the ROS.
 
Note: These letters may be accessed on the ACEP Web site (www.acep.org) under "reimbursement" in the E/M practice section.
 
In the previous example of the patient with a cough and sore throat, the HPI included the review of symptoms for the respiratory system and for the ear, nose and throat systems. At this point, the physician has recorded sufficient information to meet the minimum standard for a detailed ROS (i.e., reviewing two separate systems for symptoms).
 
Smith adds that the ROS may include either the presence or absence of symptoms. "For instance, the record may show that the patient denied having symptoms related to ears, nose and throat. Although there were no symptoms, this line of questioning also represents one of the systems reviewed during the process of history. Its purpose is to determine if the patient may also have an ear or sinus infection, or other possible cause for the symptom. Recording this additional data is clinically important and serves to strengthen the fact that the systems were indeed reviewed." In fact, Medicare explicitly states that both the positive and pertinent negative responses should be noted.
 
The second factor contributing to coders' confusion, Smith adds, is that the ROS does not need to be recorded separately in the report. Instead, if one or more symptoms involving an organ system are mentioned in the HPI, it is appropriate to consider the system as reviewed for the purpose of counting systems as required by documentation guidelines. "Physicians can actually list symptoms related to organ systems in any part of the HPI, the ROS, the past/family/social history (PFSH), as well as in a progress note in the ED," he says.

Besides official documentation supporting an ED physician's ability to report a system in both sections, Callaway says common sense also validates this practice, especially with complex cases. "If a practice approaches this issue in a very conservative manner and counts these elements only once, they would routinely be assigning significantly lower level codes for complicated cases. Let's say a patient comes into the ED with four or more systems that were documented in the HPI. If the practice were not allowed to count any of them in the ROS, it would be forced to assign a more basic E/M service even though the case is complex and the work performed justifies a higher-paying code."
 
For instance, an elderly male patient is seen because of coughing, tightness in his chest, nasal congestion, severe headache and a skin rash. The HPI would include references to his lungs, heart, ENT, head and skin. If the physician could reference none of these systems during the ROS, the level of service might be lower even though the patient presented with multiple symptoms suggesting complex care.
 
Callaway cautions that the widespread debate about counting an organ system twice has caused a handful of carriers to prohibit this practice. "Some local carriers have actually implemented policies disallowing ED physicians from counting elements in both the HPI and ROS, even though this stance is not supported by national policy. This has occurred because of a great deal of erroneous information that has been presented at conferences or published in professional publications. It would be wise for coders who aren't sure about their carrier's policy to check with their local Medicare medical directors."