Health Information Management

How to assign the correct ED E/M code

JustCoding News: Outpatient, September 5, 2012

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Physicians and facilities use the same codes to report evaluation and management (E/M) levels for emergency department (ED) services, but follow different rules. For example, when determining a visit level, physician coders only count the work performed by the ED physician or supervised mid-level practitioners, while facility coders also include work performed by nurses, consultants, and ED services.  

“Regardless of who provides the surgical procedure or service in your ED, you bill the facility component for that,” says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA-Approved ICD-10-CM/PCS Trainer, president of Edelberg Compliance Associates in Baton Rouge, La. “It’s also imperative that detailed orders, op notes, and discharge instructions for follow-up are documented appropriately because you want to capture all of the resources used for that patient in your ED.”
 
Coders also need to remember that they can separately bill procedures—not just for the ED physician, but for any provider in the ED.
 
“The rules are very different even though we use the same codes,” says Edelberg. “We define them very differently on the facility side.”
 
CMS has not created any national E/M visit level guidelines, and according to the 2013 OPPS proposed rule, it has no plans to create them any time soon. That means facilities must create their own guidelines.
 
Understand the difference between physician and facility ED E/M
Physician and nursing rules and resources, which play a part in determining E/M levels, are also different when it comes to the ED, Edelberg says. For example, physicians generally don’t provide one-on-one care to a difficult patient, but an ED nurse may have to stay at that patient’s bedside for an extended period of time. “You need to find some way to include those services in your criteria,” she adds.
Because of those differences, facility E/M levels are not always the same as physician E/M levels, says Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, director of education for the AAPC in Salt Lake City.
 
Documentation requirements also differ, Jimenez adds. What a physician documents for a professional E/M level often varies from what the facility needs to include in its documentation. One level is often higher than the other, partially because of the different requirements but also because of which provider documented what information.
 
If a physician fails to document time spent with a patient, the physician can’t bill for it. However, a nurse or other provider may document the amount of time each caregiver spends with the patient, and if so, the facility can use that information to determine an ED E/M level.
 
Facility coders must also note the type of ED where the services were provided: Type A or Type B. CMS defines the two very differently and coders report different codes depending on the location.
 
For Type A EDs, coders use CPT codes 99281–99283 with status indicator V (clinic or ED visit) and codes 99284–99285 with status indicator Q3 (codes that may be paid through a composite APC).
For Type B EDs, coders report HCPCS codes G0380–G0383 with status indicator V and G0384 with status indicator Q3.
 
The presenting problem, history, and findings of the physical examination determine the level of medical decision-making; combined, they present a more complete picture of the problem and the care required during the ED stay, or the level of follow-up/disposition required.
 
 Know why the patient came into the ED
A patient’s presenting problem is the disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the patient’s visit to the ED. It may be a significant indicator of medical necessity and support the need for ED treatment of the condition, the underlying reason for the ED course, and the medical necessity of diagnostic tests and therapeutic services.
 
The nature of the presenting problem is one of the three essential elements in determining the level of medical decision-making and medical necessity for the ED visit. Below are the guidelines and CPT® codes for the five levels of presenting problems:
 
  • Minimal (generally not applicable in emergency medicine): a problem that may not require the presence of the physician, but service is provided under the physician’s supervision.
  • Self-limited or minor (99281): a problem that runs a definite and prescribed course, is transient, and is not likely to permanently alter the patient’s health status or has a good prognosis with management/compliance.
  • Low severity (99283): a problem where the risk of morbidity without treatment is low, there is little to no risk of mortality without treatment, and full recovery without functional impairment is expected.
  • High severity, requires urgent evaluation by the physician but does not pose threat to life or physiologic function (99284): a problem where the risk of morbidity (illness, disease) without treatment is high to extreme; there is a moderate to high risk of mortality (death) without treatment or a high probability of severe, prolonged functional impairment.
  • High severity, poses an immediate significant threat to life or physiologic function (99285): a problem where the risk of morbidity (illness, disease) without treatment is high to extreme; there is a moderate to high risk of mortality (death) without treatment or a high probability of severe, prolonged functional impairment.
Review management decisions
One aspect to consider is the management decisions behind the facility’s leveling criteria, Edelberg says—in other words, the rationale for the different levels. Patients come in with presenting problems, and what happens in an ED builds from the patient’s chief complaint or presenting problem, she says. Specifically, the presenting problem determines the management decisions a physician makes about what tests or treatment the patient needs.

 

Nurses often work off of standing orders in the ED depending on the patient’s presenting problem, onset, and risk factors. Coders and anyone involved in creating ED E/M criteria need to understand what diagnostic tests and interventions are normal for common problems. That will help coders recognize when a patient’s treatment is becoming more extensive than normal, Edelberg says.
 
Consider a patient who comes in with a urinary tract infection. The patient will likely undergo a urinalysis, and depending on the results, the physician may simply provide medication and send the patient home. However, if the patient needs a more extensive workup and requires IV fluids, he or she has moved into a higher level of acuity, Edelberg says. The patient has more risk factors and requires a more extensive intervention, resulting in a higher E/M level.
 
“You want to look at the range of treatments for your more common complaints in the emergency department and have a very good understanding of what the range of services is,” Edelberg says.
For example, a patient may have a minor single-system problem, such as a small cut on the finger, or a more significant single-system problem that requires a complicated procedure. “You don’t want to get too hung up on a single-system problem when the problem is treated with complicated procedures or complicated interventions,” Edelberg says.
 
When a patient presents with multisystem problems, those problems can require minor interventions, complex interventions, or both, Edelberg says. The more that is done for a patient, the higher the level of acuity becomes.
 
Any of the following complicating factors, among others, can increase a patient’s acuity level and result in a more complex level of medical decision-making:
  • Infection
  • Coumadin use
  • Elevated blood pressure
  • Severe pain
  • Consultation with additional providers
  • Extended ED course for observation of recovery/results
  • Diabetes
  • Poor hygiene
  • Multiple differential diagnoses
  • Systemic problems
  • Suicidal/homicidal ideations
  • Combative tendencies
Consider variation among payers
Most EDs don’t bill only to Medicare, so coders need to be aware of what rules each payer has in place. Some will pay for procedures in addition to an ED E/M visit, while others will bundle different combinations of services, Edelberg says. “It’s always a good process to understand what all of your major payers are doing with regard to paying your facility visits and any feedback they provide.”
 
The best way to do that is to visit the payer’s website and download any published criteria or guidance, she says.
 
Also, make sure someone reviews payer denials to ensure the coders on the front end understand what happens on the back end. “You may not be able to get information up front from all of the payers,”
Edelberg says. “You can certainly get it on the back end when they deny certain combinations of codes.”
In addition, knowing what payers are and are not paying for will help facilities further tweak their E/M criteria, Edelberg adds. “The rules are very confusing,” she says. “If you don’t really stay on top of them and make sure everyone understands why you do what you do, you can lose control of those criteria.”
 
E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.

 



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