ED Coding and Reimbursement Alert

Questions: This chart is causing arguments among my coders over what E/M code to report and whether the attestation statements hold up to report all the procedures documented. Can you help?

Texas Subscriber

Chief Complaint

Patient presents with: Cardiac Arrest

I was unable to obtain a clear HPI, ROS from the patient or review their PMH, FH, SH due to acuity of condition (patient not responsive).

HPI

XXX is a 67 y.o. male with a PMH of CAD s/p CABG (10/3/2013), Atrial fib on Coumadin, aortic stenosis, mitral regurgitation s/p MVR (10/5/2013), heart failure, pulmonary HTN, s/p gastric bypass (2002) and multiple hernia repairs who presents to the ED c/o cardiac arrest. Patient’s wife reports the patient had been feeling fatigued for the past week. He had poor PO intake and increased sleep during this time, but had been taking all his medications. He was scheduled to see Cardiology today and when he arrived for his appointment he stopped to use the bathrooms in the main lobby. His son helped him into the bathroom because he had been feeling weak previously and required wheelchair assistance when entering the hospital. When the son went to check on him, he found the patient had collapsed on the bathroom floor. The patient was then placed in a wheelchair and brought to the ED at 09:45 am.

Review of Systems: Unable to perform ROS: Acuity of condition

Past Medical History

Aortic stenosis
Hypertension
Arrhythmia
Atrial Fib
Atrial fibrillation
Pulmonary hypertension
Restrictive lung disease
OSA (obstructive sleep apnea)
GERD (gastroesophageal reflux disease)
PMH GI ulcer at gastric bypass anastomosis
Hydrocele bilateral-followed by urology
Obesity
Stasis leg ulcer left leg; chronic
Anemia following gastric bypass with GI ulcer at anastomosis
Heart murmur
Aortic stenosis and mitral regurgitation
Past Surgical History
Gastric bypass surgery
Umbilical hernia repair

Family History

Father — Kidney Disease   Alzheimer’s Disease
Mother — Diabetes
Brother — Hypertension Heart Disease

Social History Married, Never Smoker. Alcohol Use: No. Sexually Active: Yes — Female partner(s).

Social History Narrative

Patient is a retired welder. Patient is from a small town about 60 miles from here. Patient has two sons. Patient has no grandchildren. Patient is currently disabled.

Prior to Admission medications

AtorvaSTATin (LIPITOR) 10 MG tablet Take 1 tablet by mouth every evening
Bumetanide (BUMEX) 2 MG tablet Take two tabs twice daily (4mg twice daily)
Calcium Citrate-Vitamin D (CITRACAL + D PO) Take 2 tablets by mouth 2 times daily.=
Iron 66 MG TABS Take 1 tablet by mouth daily.=
Metolazone (ZAROXOLYN) 2.5 MG tablet Take 1 tablet by mouth once a week
Multiple Vitamins-Minerals (CENTRUM PO) Take 1 tablet by mouth daily
OxyCODONE HCl (OXYCONTIN PO) Take 60 mg by mouth As Specified
Pantoprazole Sodium (PROTONIX) 40 MG PACK Take 1 tablet by mouth daily
Potassium chloride SA (K-DUR;KLOR-CON) 20 MEQ tablet Take 2 tablets by mouth 2 times daily
Sildenafil (REVATIO) 20 MG tablet Take 1 tablet by mouth 3 times daily do not take with nitrates
Spironolactone (ALDACTONE) 25 MG tablet Take 1 tablet by mouth daily
Warfarin (COUMADIN) 5 MG tablet Take 1 tablet by mouth daily
No Known Allergies

Physical Exam

BP: 117/66
Nursing note and vitals reviewed.
Constitutional: Unconscious. Flaccid.
Head: Normocephalic and atraumatic.
Mouth/Throat: Oropharynx is clear.
Neck: Neck supple.
Cardiovascular: Pulseless.
Pulmonary/Chest: No spontaneous respirations. 
Abdominal: Soft. Bruising over abdomen.
Musculoskeletal: Wraps over BLE.  
Neurological: Non-responsive. Alert and oriented times 0.
Skin: Gray in appearance.

Procedures

Ultrasound documentation:

A cardiac ultrasound performed shortly after onset of CPR.

Cardiac ultrasound: A bedside cardiac ultrasound was performed by Dr. Resident. The medical necessity was to evaluate for cardiac activity and pericardial effusion. The structures studied were the heart and pericardium. The interpretation was no organized cardiac activity or pericardial effusion.

A second cardiac ultrasound was performed just prior to terminating CPR.

Cardiac ultrasound: A bedside cardiac ultrasound was performed by Dr. Resident. The medical necessity was to evaluate for cardiac activity and pericardial effusion. The structures studied were the heart and pericardium. The interpretation was no organized cardiac activity or pericardial effusion.

After a review of the patient’s case the resident performed the ultrasounds under my supervision. I was present for the entire procedure(s).

Attending, MD

Intubation

The patient was ventilated with 100% oxygen using a bag-valve-mask prior to the procedure. Patient’s oxygen saturation prior to the procedure was unknown. The patient was intubated orally using a # 4 Macintosh and an 8.0 Fr. ETT. The tube was placed on the 1st attempt. The patient was subsequently ventilated using a bag-valve-mask. Placement was verified by a CO2 detector. Patient’s oxygen saturation following procedure was 95%. The patient tolerated the procedure well.

Resident, MD

After a review of the patient’s case the resident performed the endotracheal intubation under my supervision. I was present for the entire procedure(s).

Attending, MD

Central Line

A central line was placed at 10:00 by Dr. Resident and Dr. Attending. The situation was emergent, and consent was not obtained. The medical necessity was for vascular access. The patient was not sedated and in a flat position. The line was placed successfully on the 2nd attempt in the right femoral using a 9 FR double lumen catheter. Ultrasound guidance was not used. Line assessment was determined by blood return through all parts and the line was sutured. The patient tolerated the procedure well with no immediate complications.

Resident, MD

After a review of the patient’s case the resident performed the central line insertion under my supervision and with my direct assistance. I was present for the entire procedure(s).

Attending, MD

Arterial Line

An arterial line was placed in the right femoral artery by Dr. Resident and Dr. Attending. The situation was emergent, and consent was not obtained. The medical necessity was for arterial vascular access.  Placement was verified by blood return and waveform on monitor. The site was dressed using a sterile technique. The patient tolerated the procedure well.

After a review of the patient’s case the resident performed the arterial line insertion under my supervision.  I was present for the entire procedure(s).

Attending, MD

Medical Decision Making

Extensive labs were ordered with venous blood gases, sodium, potassium, glucoses and lactic acid all showing as abnormal.

ED Course: Mr. XXX was brought to room obtunded, pulseless and apneic; he was taken from the wheelchair to bed with the only history that he collapsed in bathroom in lobby while on his way to cardiology appointment. Family said he was feeling weak for the past 4 days. CPR was immediately started by Dr. Attending and airway support was started by Dr. Resident. 18 gauge IV established in left AC and epinephrine was given, CPR continued while the drug was circulated and a pulse check revealed fine V-Fib rhythm, a shock was delivered and faint pulse detected at the carotid but was quickly lost after less than 1 minute. CPR was resumed, Amiodarone was given as this seemed a refractory V-Fib and in addition Bicarb was given and another round of Epi was given. At this point another rhythm check revealed fine V-Fib and another shock was delivered. US revealed no coordinated cardiac activity and CPR was again resumed. Right femoral central line was placed at this point. VBG had returned and showed a K=8.2, I had Calcium gluconate given at this point and circulated the drug. There was no ROSC since the first time the patient was defibrillated.  Mr. XXX’s wife was brought outside the trauma bay, Mr. XXX was intubated at this point and I explained to Mrs. XXX and her son that about 15 minutes had gone by without cerebral perfusion. I brought both Mrs. XXX and her son into the resuscitation bay for the final couple minutes of the resuscitation. I explained that if there was still no coordinated cardiac activity after 15 minutes that Mr. XXX would not recover neurologically. There was no coordinated activity and Mr. XXX would be pronounced at this point. The rhythm was fine V-Fib refractory to defibrillation during the resuscitation. This was not a medical examiner case and cause of death was acute coronary insufficiency. Time of Death was approximately 10:47am Nov. 12, 2014.

Attestations:

I have personally seen and evaluated this patient reviewed the resident’s findings and directed the plan of care. The patient was sadly found to be in cardiac arrest upon presentation and despite intubation  and CPR along with rigorous ACLS care under my direction the code was unsuccessful.

Attending, MD

The resident and attending physician obtained and performed the history, physical exam and medical decision making elements that were entered into the chart by me.

Scribe XX scribing on behalf of resident Dr Smith and Attending Dr Wilson

I provided 30-74 minutes of critical care for this patient.

Resident, MD

Scribe entries full reviewed and consistent with my personal care. Electronically Signed By:

Attending, MD

Answer: This is a complicated chart because involves a scribe, a resident, along with the emergency physician, so you will want to watch the attestation statements to be sure who documented each segment and what is billable as a result.

Clearly this is a very sick patient. You could easily make a case for reporting 99291 (Critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes) but the critical care time documentation is from the resident only and as a result, not billable. Additionally, the time threshold would not likely be met when you back out the time spent providing the numerous procedures from the approximately one hour the patient was in the ED.

The documentation does support a level five ED E/M service if you invoke the acuity caveat based on the documented statement, “the only history that he collapsed in bathroom in lobby while on his way to cardiology appointment,” to account for the lack of a documented review of systems.

There is no direct attending note for the CPR, ET tube placement or the ultrasound studies but there are attestations.

There is also no resident validation for scribe documentation, but there is attending validation. Additionally, the attending physician’s documentation and attestation of the ED Course seems to confirm his or her presence for the entire duration of the visit.  Although defibrillation is documented, there is no code to describe that service outside of CPR or critical care.

On the Claim report:

99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity…)

Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to show the E/M service is separate from the procedures performed.

92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest])

Append modifier 26 (Professional component) to 93380 to show you are only reporting the professional component.

93308-26 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, follow-up or limited study)

Also append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) to the second ultrasound study procedure to indicate it is a repeat procedure by same physician.

93308-26-76

31500 (Intubation, endotracheal, emergency procedure)

36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older)

36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous)