ED Coding and Reimbursement Alert

7 tips to perfect your E/M choices

If indecision about medical decision-making is throwing your E/M reporting for a loop, consult these seven helpful documentation hints to simplify your
code selections.
 
1. Ask the physician to list complicating factors. These could include comorbidities, other chronic conditions the patient may have, medications the patient is already taking, or adverse reactions the patient had to previous medications, says Lori-Lynne Webb, director of coding and compliance with Saltzer Medical Group in Nampa, Idaho.
 
For example, if a physician prescribes two or three medications, talks to a consultant, and re-evaluates the patient twice, the case might warrant a level four (99284) or five (99285), depending on the risk to the patient and the kind of tests performed. Your key to success here is to make sure the physician documents the case's complexity - not just the diagnosis and procedures.
 
2. Look at the tests and medications the physicians ordered for clues to the extra complexity the physician may not be explaining, says Jean Keller, an auditor with Applied Medical Services in Durham, N.C. Look in the history of present illness and review of systems to determine what the physician is trying to rule out, but also encourage the physician to state what diagnoses he hopes to rule out or confirm.
 
If a diagnosis is not definitive, make sure your physician has documented pertinent signs and symptoms. For instance, if the patient is stable, look for statements telling you whether she has shown improvement or is worsening and whether the doctor has planned a workup.
 
Tip: The best way to do this is to encourage the physician to document a differential diagnosis.
 
3. Have the physicians dictate records on their level-four or -five visits instead of using a checklist or template, Keller says. Some templates don't give enough room to explain why the physician made some decisions, and often physicians won't even use the spaces provided.
 
4. Use the MDM to predict the E/M level, before spending time counting the review-of-systems elements and evaluating the physical exam, says Rebecca Sharp, CPC, coding and physician education manager at Computer Sciences Corporation in El Segundo, Calif.
 
"I first look at the chief complaint, but then turn my attention to the MDM," agrees Nettie McFarland, RHIT, CCS-P, coding manager at DuvaSawko in Daytona Beach, Fla. "It can be a real time saver when reviewing the history and exams of lower levels."
  
5. Don't code a higher level of decision-making than the documentation supports. Often, coders will boost the MDM because they know the patients are in really bad shape, says Marcella Bucknam, CPC, CPC-H, HIM coordinator with Clarkson College in Omaha, Neb. "They get emotionally involved in the complexity of the problem and don't code what the doctor wrote down," she says.
 
Unless you are invoking the acuity caveat for 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity), documentation must support the chosen code.
 
Even with 99285, remember that you have to justify the hole in documentation in order to receive reimbursement - the insurer will need to know exactly why you invoked the caveat. See the article "Secure Level-5 E/M Pay With the Acuity Caveat" in the January 2004 issue of ED Coding Alert for more information on the topic.
 
6. Tell physicians they should make clear when they're taking an intermediate step that they don't believe will solve the patient's problem. For instance, some    back-pain patients will receive a trial of nonsteroidals in the emergency department, but if the pain continues and requires narcotics, the physician may decide to investigate further and order x-rays. Explaining that they're trying the more conservative treatment - but that the patient may require a more aggressive approach - can boost the level of MDM, Bucknam says.
 
7. Ask for more details if the physician writes something like "labs reviewed," Keller says. The patient may have had an adverse reaction to something he received in the emergency department. Likewise, if the physician followed up on the patient's blood pressure, find out what was wrong with the patient's blood pressure earlier.