EM Coding Alert

Hint: Don’t lean on H&P documentation for leveling.

Patients that report to the emergency department (ED) for treatment are nearly certain to receive an ED E/M service. When this occurs, there are several areas of concern that could trip up your coding.

Find out what coders and clinicians need to know to nail down ED E/M claims, from expert Lori A. Cox, MBA, CPC, CPMA, CPC-I, CEMC CGSC, CHONC, who presented on “Emergency in DC: How to Level E/M Services in the ED” at AAPC’s HEALTHCON 2023.

Stay Wary of Lacking Documentation on H&P

One area that many claims are lacking is documentation of history/physical exam (H&P). According to Medicare, E/M codes with levels include a medically appropriate history and/or physical examination, when performed. The extent of history and physical examination is not an element in selection of the level of these E/M service codes since the codes were revised for 2023.

This, Cox said, has led to problems on claims for 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) — especially since H&P isn’t explicitly called for anymore.

“When they changed history and exam for code criteria, it was never intended that you just stopped doing it,” explained Cox, director of client engagement at AAPC. However, she’s seeing some encounter forms that aren’t giving coders enough information to select the appropriate code.

“[H&P] is important, and as coders and auditors [we] need that information, because there’s a lot of really good information that we find in there, as far as how severe the condition is,” she continued.

Why? So, if the ED E/M descriptors dropped H&P as an element in leveling, why do providers and coders need to be so concerned about it? It will help illustrate “the severity of that condition, and how the patient is presenting is extremely important,” said Cox. There will be pieces of information gathered during H&P that will be influencing the providers’ differential diagnoses; H&P also needs to be present in order to justify providing services beyond the E/M.

Find the Proof in the Paperwork

The complexity of the E/M visit also needs to be evident in the documentation. This should be relatively easy in the ED because providers there “spend their time assessing the acuity of what needs to be done right away for patients,” Cox explained. “Unless they’re using your ED as their primary care physician, patients are usually coming in because something is really wrong that they need addressed.”

This makes complexity clearer for emergency medicine than in other specialties, where you are managing multiple conditions or providing long-term care for your patients. Still, coders need to keep providers on the ball when documenting elements that the coder can use to make a decision on encounter complexity.

“I think emergency department providers, on average, do a much better job here. I usually see EDs doing this a lot better than some of the others that we’ve audited,” reported Cox.

Focus in on Cause and Treatment Specificity

In determining an ED E/M level, the coder must know what the physician is treating specifically. They must also know what underlying conditions the patient has, which might contribute to the overall complexity of the encounter.

“This is what we see if you’re in a large health system and they’re pulling in information from other sources, especially when it comes to chronic conditions. Has that chronic condition really influenced the care that they’re receiving in the emergency department? Has it impacted treatment for that patient on that day?” Cox asked.

That doesn’t mean you cannot factor in other conditions the patient might suffer from when treating a different issue — their relationship just needs to be reflected in the documentation.

“We know when patients come in with an acute problem, lots of times their comorbidities or chronic conditions are going to impact how that physician is going to assess the patient and certain things that they might do for the patient. But we still need to see that linkage in the documentation,” she said.

Follow the Journey from Presentation to Dx

Let’s say a patient presents with chest pain and shortness of breath, but it ended up that the patient had indigestion rather than something more serious like a heart attack. The physician treated the patient like a heart attack patient because that’s how they presented.

“One of the things that we deal with in the emergency department is … it might seem at the end of the encounter that the patient has something not so serious. But the doctor’s done a lot of work-up through the encounter to come to that conclusion,” said Cox.

So, when figuring ED E/M level, “it’s not just that final diagnosis and how severe it is. It’s how did that patient present? What were the differential diagnoses that they were investigating, to come to the conclusion that the patient is not severe enough to stay in the hospital and ready to go home? And what type of interventions they’re going to need while they’re there?” posited Cox.