Wiki E&M done before emergent procedure

[Chelsea1]

Our Cardiologists see patients via the ER all the time. Often than not, patients
come in with Heart Attacks and need to be taken emergently to the Cath Lab.
At times, due to the situation, we find the History, Examination, and Medical
Decision Making is lacking information. My question is, due to the circumstances at hand, can I code a higher level? If this would be the case, where would I be able to locate information regarding this? Unable to find anything related to this type of case.
I appreciate any help!

 

[jimbo1231]

Caveat ?

I think you are talking about what is called the history caveat. Basically if the patient condition precludes taking a complete history and the docs document the condition; ie altered mental status etc; the history requirements are waived. But the attempt should also be made to get the history from the family or other sources if available. But if the only issue is the patient went to the Cath Lab and taking the history is inconvenient, the caveat wouldn't apply.

If your cardiologists are coming to the ED, there might be documentation available from the ED providers. Of course that documentation is subject privacy laws so they should be certain that they are covered in the release of information.

Jim S.

 

[LLovett]

Depends on who the carrier is

WPS Medicare does not allow for any automatic levels based on the scenario. They say you have to code based on what is documented. If there is not enough to support any defined code, you go unlisted 99499. You need to check with the carrier in question to determine what is acceptable for them.

http://www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0526_emqahistory.shtml

Q 2. Where does it state that if the history is unobtainable you cannot automatically bill a comprehensive history? Do you automatically have to bill based on a problem-focused history?
A 2. There is nothing notated in the 1995 or 1997 DG to indicate any level of history is automatic. The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document the history (if any) that is available.

Q 3. We are unable to obtain history as the patient is intubated. Do we have to bill a Not Otherwise Classified (NOC) code?
A 3. You would only submit a NOC code when you are unable to document any of the history elements. If you are talking to the patient's family or others to obtain history, document the work performed and code based on the work performed. The use of the NOC (99499) should be very rare.

Hope this helps,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC