Wiki ED charging help

[Kelle]

We have been doing the charging for the physician and facility side in our institution for over a year. Recently we went to an automated ED documentation system. This system picks up triggers in the documentation and assigns the facility side E&M level for the encounter. We were told previously that we not only have to have a physician order but the documentation (ie. cardiac monitor strips, multiple pulse oximetry print outs) in order to prove these interventions were done and charge that particular E&M level. We are now being told that we don't need these documents or even a physician order to justify the level of service being assigned. We can't find the documentation about this to prove our point. Can someone steer us in the right direction so we can back up the point we are trying to make? Any help would be greatly appreciated.

 

[ahinman]

We have an ER documentation system that sounds a lot like yours. Remember the people that are telling you what you need and don't need are most of the time sales people or clinical people that don't do coding. I would be very careful about just letting triggers pick your levels for you. This can get messy and you might want to look over these. I found with our system that it likes to "double dip". I am very interested to know what system it is that you have. If you don't want to put the name of it on the board would you send me a private message. If it is the same system maybe I can share some helpful hints with you.

 

[OCD_coder]

Your level of service is guided by the NOPP (nature of the presenting problem) and the complexity of the data (MDM). This information is in the guidelines of the CPT book.

To determine a level of service should not be guided by "boxed" key information. Computer programs will never be able to take out the human decision making factor of E/M coding by inputting "trigger" information.

 

[mitchellde]

Your level of service is guided by the NOPP (nature of the presenting problem) and the complexity of the data (MDM). This information is in the guidelines of the CPT book.

To determine a level of service should not be guided by "boxed" key information. Computer programs will never be able to take out the human decision making factor of E/M coding by inputting "trigger" information.

That is for physician not the facility. My question is; Is this program assigning both the physician as well as the facility level? And if it is assigning the facility level is your facilities criteria a part of the programs data base?