ED Coding and Reimbursement Alert

Question: A patient presented in the ED with sudden onset of pain in the left side of his head, nausea, and weakness. We performed a CT scan and lumbar puncture to rule out a subarachnoid bleed. I have four HPI elements, six ROS, two PFSH, and eight organ systems examined. Because of the conscious sedation for the lumbar puncture, the MDM supports a risk of level five. The insurer's coding department reviewed the chart and it disagreed, saying it doesn't meet the requirements for a level-five service. Who is correct?


Indiana Subscriber


Answer: In this case, your payer is correct and the chart did not meet the criteria for 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three 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).

Your -medical decision-making- and -nature of presenting problem- elements satisfy 99285's requirements, but CPT rules also require a complete review of systems (ROS) to report a level five. A complete ROS means that in theory the physician reviewed all 14 systems--not just the affected one, according to CPT. Most experts and auditors default to the commonly used 10 ROS elements specified in the 1995 Documentation Guidelines.

In this case, your six-element ROS supports only a detailed history, not a comprehensive one.

If for some reason the patient's condition prevents the physician from performing a complete ROS, the reason should be in the documentation. This chart would probably be a great one to download and show to your physicians for educational purposes.