Wiki Question about E&M in ED

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LuckyLily

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I have come across several situations recently where there are varying ideas on how to code properly.

Example 1: patient comes into ED with complaint of feeling foreign body in eye. The physician documents in exam portion that s/he exams the eye and determines not foreign body, but has a corneal laceration. The only system examined is the eye. One coder wants it as a level 99281 because of only one organ system is examined and another a level 99283 because other portions HPI and MDM are higher.

Example 2:patient comes into ED (new problem) and gets worked up for abdominal pain. An ultrasound is done and is determined that patient has GERD. While in ED the patient is given a GI cocktail to help relieve pain. The ED physician recommends the patient should see a Gastroenterologist. My question is, would this be considered "New problem, no additional work-up" or "New problem additional work up". How do you determine the "work-up" portion if patients are seen and always referred to see either PCP or specialty doctor.

Thanks for any advice on E&M for emergency department.
 
LuckyLily said:
I have come across several situations recently where there are varying ideas on how to code properly.

Example 1: patient comes into ED with complaint of feeling foreign body in eye. The physician documents in exam portion that s/he exams the eye and determines not foreign body, but has a corneal laceration. The only system examined is the eye. One coder wants it as a level 99281 because of only one organ system is examined and another a level 99283 because other portions HPI and MDM are higher.

Example 2:patient comes into ED (new problem) and gets worked up for abdominal pain. An ultrasound is done and is determined that patient has GERD. While in ED the patient is given a GI cocktail to help relieve pain. The ED physician recommends the patient should see a Gastroenterologist. My question is, would this be considered "New problem, no additional work-up" or "New problem additional work up". How do you determine the "work-up" portion if patients are seen and always referred to see either PCP or specialty doctor.

Thanks for any advice on E&M for emergency department.
Click to expand...

Example #1 - ED E/M codes must meet or exceed all 3 components - History, Exam and MDM - just because the other areas are higher you can't up-code. So if only one exam area was examined, than the highest level billed could only be 99281 no matter whether he does a higher level History or MDM! I would double check that he only did one exam area though as I would assume that the patient's vitals were also done, which would be at least an Expanded problem focused exam with 2 systems.

Example #2 - This would be "new problem, additional work-up" because the physician ordered the ultrasound. Additional work-up is for when the physician orders further testing Referring a patient to follow-up with another physician is not additional work-up for the ED physician as he will not be doing any further care for that patient.
 
Thank you jdibble.

For example 1 I would agree to code 99281. The vitals were not listed within the exam.

Example 2: I have another question. So every time a patient has lab, radiology, EKG done while in the ED it is always considered "additional work up". It was explained to me that it would be "additional work up" if the patient was admitted.
 
Additional work-up Planned

LuckyLily said:
Thank you jdibble.

For example 1 I would agree to code 99281. The vitals were not listed within the exam.

Example 2: I have another question. So every time a patient has lab, radiology, EKG done while in the ED it is always considered "additional work up". It was explained to me that it would be "additional work up" if the patient was admitted.
Click to expand...

Below is excerpt from a FAQ sheet on the Marshfield Clinic Scoring Tool. I found this on the American College of Emergency Physicians site. Sorry I couldn't get the URL.

"In the Emergency Department, because of the ready availability of comprehensive
diagnostic testing, assessments are frequently shortened to a single E/M encounter, with
the work-up performed on the same day. It would make no sense to penalize an ED
physician for efficiently assessing and managing the patient’s presenting medical
condition, and assuring the work-up is performed in a timely manner. With regards to
Medical Decision Making, the key concept and actual language from the Marshfield
Clinic Scoring Tool is that additional work-up was “planned”, not whether it was
performed on the same day or a later date."

There is also an article from the Coding Edge from December 2007 - Medicare E/M Coding in the Emergency Department that is very good. Basically it states that the question that should be asked is “Was the physician able to make an appropriate decision before the tests were performed?” If not, than it is additional work-up planned. Also, requesting a CONSULT could be additional work-up because the doctor is looking for feed back on how to treat the patient - not to be confused with referring the patient to a specialist at discharge, since the ED doctor no longer will be caring for the patient.

If your specialists does a consult on an ED patient, and uses the information from the labs, x-rays, etc. already ordered to make his decision, then that is not additional work-up. But if he decides to order an MRI that was not done yet, then he would get credit for additional work-up planned - and that would be done on the same date!

So, in response to your question - yes, that would be additional work-up. :eek:

I hope that was helpful!
 
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