ED Coding and Reimbursement Alert

Acute asthma results in about 1.5 million ED visits each year. ED physicians typically bill an E/M service for these cases. The real coding challenge comes from determining the medical decision-making for the E/M, 99281-99285 (ED visit for the evaluation and management of a patient), and deciding when to choose 99285 versus 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).
  
Caral Edelberg, CPC, CCS-P, president and CEO of Medical Management Resources Inc. in Jacksonville, Fla., strongly advocates and uses a system that will guide coders through what could be an arduous process. At the American College of Emergency Physicians (ACEP) conference "Getting Control: Effective Procedure Coding for Emergency Medicine" held in New Orleans last May, Edelberg introduced "building blocks" (a process based on the original ACEP concept) to simplify selection of the proper medical decision-making (MDM) level. With this system, the lowest E/M level begins with a limited number of physician-performed procedures and/or nursing orders, and as more services are recorded the level increases accordingly. All of this assumes, however, that the history and physical levels are consistent with the E/M level of MDM.
 
This building-block system is designed for determining E/M levels for any coding situation, so, after hearing about it during Edelberg's presentation, Barbara Steiner, RN, ART, ER coding coordinator for Gastonia Memorial Hospital in Gastonia, N.C., applied it to coding ED asthma visits. "The building blocks provide a good assessment of the procedures the physician performed," Steiner says. "In many instances, we were able to effectively and legitimately move up a level simply by following the building-blocks grid. For example, if the physician performs all the procedures listed under level two (99282) and adds a nebulizer treatment, the coder might be able to identify the treatment as level three (99283). And, according to the 2001 Medicare RBRVS Physician Fee Schedule, level two has a relative value unit (RVU) of .80 compared to a level three, with 1.69. We've already seen a significant boost in revenue for asthma billing.
Determining Appropriate E/M Levels for ED Asthma Visits  
The grid of asthma building blocks, based on Edelberg's original design, is broken down as follows (see box on page 51 for a complete list):
 
Levels One (99281) and Two (99282): The grid lists physician assessment, vital signs and prescription refill for a level one. But, Tracie Christian, CPC, CCS-P, director of coding for ProCode in Dallas, says proper documentation of even the lowest asthma presentation can usually support a level-two E/M (99282).
 
The list of level-two procedures includes all those in level one plus pulse oximetry. A classic example of a level-two service is the asthmatic patient who presents to the [...]