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.

 
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 ED with minor wheezing and, before the physician begins treatment, the wheezing subsides. In this case, the ED physician would more than likely execute a pulse-oximetry test and decide the patient requires no laboratory or radiological testing or breathing treatments, and instead prescribes only an inhaler before the patient's discharge. Based on the building-block grid, this scenario constitutes low MDM to support an E/M level 99282.
 

Level Three (99283): This visit could involve a patient who presents to the ED with wheezing and states that the home-nebulizer treatment failed. At this point, the ED physician might document a pulse-oximetry interpretation of 94 percent and order a nebulizer treatment and chest x-ray (CXR) to rule out any related problems. If the CXR shows no other warning signs and the wheezing resolves after the first nebulizer treatment, the ED physician might discharge the patient with instructions and prescription medications. Documentation of the pulse-oximetry interpretation, nebulizer-treatment results and interpretation of the CXR would support 99283 -- if the required E/M physician-documentation guidelines were met.
 

Level Four (99284): The procedures listed on the asthma building-blocks grid include all those listed for the first three levels. However, level four also includes two or more pulse-oximetry tests, two or more nebulizer treatments, IM or IV medication, blood gases, x-rays, labs, consult with patient's primary care provider, oxygen, IV fluids and possibly an ED admission. Selecting and implementing five or more additional procedures from the list qualifies the visit as a level four.   
 
Perhaps an ED physician treats a patient who does not respond to the first nebulizer treatment and shows suspicious infiltrates on the CXR. The doctor then might order a second or even a third nebulizer treatment and record several pulse-oximetry interpretations. Documentation of the CXR interpretation and a review of the patient's prior records may induce the physician to even administer IV medications. For this moderate level of MDM, complete documentation of the other required E/M elements (history of present illness [HPI]; personal, family and social history [PFSH]; review of systems [ROS]; and exam) would easily support 99284.
 

Level Five (99285): Service typically reaches level five when the physician performs three or more pulse-oximetry tests and three or more nebulizer treatments and provides two or more appropriate medications. The ED physician performs these procedures on top of those listed for level four. This is where documentation is critical, Steiner says. "If the physician isn't careful to report all of the tests performed, even an admission to the ICU might make it difficult to code the case as level five."
 
Remember, individual circumstances will affect the coding, and in the above examples the level could go up or down depending on the work provided. For example, just because a patient is not admitted to an intensive-care unit, that does not mean the chart may not be valued at a level five. It is absolutely conceivable that a patient who is discharged from the ED could warrant a level-five code. Proper and complete documentation for procedures and treatments must support the MDM component of the chart and truly indicate the value that should be placed on the service. But if the documentation of the history and exam does not support the value of the decision-making, the chart would have to be coded at a lower level than the decision-making value would suggest.

Critical Care Versus ED Visit

 
The RVUs jump to 4.0 if the patient is classified as critical care. According to Christian, choosing between an E/M level five (99285) and critical care (99291) can be  perplexing, because a patient's record for a 99285 might appear very similar to one that supports 99291.
 
For example, a patient who needs immediate attention and intervention to restore breathing because of severe asthma exacerbation is likely to be admitted. At this point, depending on documentation, the case seems to be a level five. But if the patient exhibits severe respiratory impairment with no improvement from nebulizer or other treatments, he or she may fit the definition of "critically ill."
 
Critical care 99291-99292 are the only ED codes that specifically include a time factor. Events in the ED might happen quickly, and level-five services can happen in a matter of a few minutes. Because critical-care codes are determined by time, it is essential for the physician to indicate that critical care did take place and how much time was involved. Only the physician can make this determination. Coding staff cannot infer that critical services were provided or determine the time the physician committed to the patient.
 
CPT made two revisions to the definition of critical care during the past two years. The CPT 2000 Manual deleted the critical-care requirement that a patient be unstable. In 2001, CPT added high probability of imminent or life-threatening deterioration in the patient's condition. The new, looser language allows EDs to code more comfortably for critical care. CPT cites an example of 99291 as the first hour of critical care of a 15-year-old with acute respiratory failure from asthma. Time is the essential aspect in reporting critical care.
 
The physician must document critical-care time devoted to the patient, exclusive of time devoted to other billable procedures. In the absence of time documented, you should observe payer guidelines, Christian says.
 
Typically a separately billable procedure like intubation is performed on a critically ill asthma patient. This, coupled with the time spent attending the patient, accounts for billing critical care instead of level five. The grid adds the separately billable procedure on top of the level-five list to indicate critical care. Remember, however, to deduct the time required for the intubation from the critical-care time.

Complete Physician Documentation Is Crucial

 
Steiner says coders can refer to the order sheet to  determine the correct E/M level if the physician documents in writing precisely what treatment was performed. "It's stickier to make the leap (to a higher-level E/M code) when the physician's documentation doesn't support the level of coding," she explains
 
Christian agrees. "Even though we might not bill for certain procedures, such as those bundled into the E/M level," Christian says, "documentation of them is essential for our coders to support appropriate E/M levels."
 
A physician's neglecting to document a procedure often forces the coder to resort to a lower-level E/M. Steiner says that although sorting through the procedures recorded on the charts is tedious, the number of procedures performed and documented can make the difference in billing one level over another.
 
For example, if the ED physician forgets to record even one procedure, that could make the difference in billing for a higher E/M service. "You can't go back to the doctors and ask them to record the procedure after the fact," Christian says.

 
Even if the level of MDM is properly documented, diagnosis coding must support the chosen E/M codes. Christian explains that ED physicians identify the classic symptoms of asthma along with results from pulmonary function tests (PFT) to confirm their diagnosis. If, during a PFT, the patient shows signs of improvement after the use of a bronchodilator, asthma is a likely diagnosis. 
 
The first coding step is to assign ICD-9 category 493.xx for asthma. The fourth digit specifies the type of asthma, and the fifth digit identifies the presence of status asthmaticus (therapy that does not reduce the degree or intensity of symptoms) or acute exacerbation (severe worsening of condition).
 
Christian says typical asthma symptoms include shortness of breath, wheezing, coughing, and tightness in the chest or chest pain. If a patient presents with one or more of these symptoms, and the physician documents the underlying cause as asthma, asthma is recorded as the principal diagnosis. The diagnosis selected should be the one that best reflects the service provided.
 
The four categories of asthma are extrinsic, intrinsic, chronic obstructive and unspecified. Use (493.0x) for extrinsic asthma (the result of exposure to external -- environmental -- allergens), which includes:

allergic asthma with stated cause of specific allergen;

asthma with hay fever;

asthma with rhinitis;

atopic asthma; and

childhood asthma.
 
Intrinsic asthma (493.1x) often follows a respiratory infection such as a common cold. Christian says other triggers include cold air, emotional stress, gastrointestinal reflux disease (GERD), sinusitis, exercise, chemical fumes and certain medications such as aspirin, beta-blockers, ibuprofen and nonsteroidal anti-inflammatory drugs. Code 493.1x also includes late-onset asthma.
 
Assign 493.2x for chronic obstructive asthma, which includes a diagnosis of asthma with chronic obstructive pulmonary disease (COPD). Automatically assign code 493.2x if a patient has COPD and asthma. If the patient has a diagnosis of chronic bronchitis or chronic asthmatic bronchitis, assign 491.2x instead, with the fifth digit identifying the presence or absence of acute exacerbation.
 
Use code 493.9x for unspecified asthma. This code includes unspecified allergic asthma, allergic bronchitis and asthmatic bronchitis. However, a code of 491.2x as stated above indicates chronic asthmatic bronchitis.
 
Effective Oct. 1, 2000, a "2" was added to the fifth-digit subclassification for category 493 to include acute exacerbation. A patient presenting to the ED with symptoms not qualifying as status asthmaticus would be categorized as acute exacerbation. Status asthmaticus is assigned a fifth digit of "1." A patient presenting to the ED with an asthma attack that failed to respond to treatment would be diagnosed with status asthmaticus.
 
Status asthmaticus includes intractable asthmatic attack; refractory asthma; severe, prolonged asthmatic attack; airway obstruction (mucous plug) not relieved by bronchodilators; and severe, intractable wheezing.
 
Assign a fifth digit of "0" if the patient presents with asthma without mention of status asthmaticus or acute exacerbation.