Medicare E/M Coding in the Emergency Department
Additional Workup Planned vs. Additional Workup Performed
By Monique Waterford, CPC, CCS-P
For many years there has been controversy over the interpretation and application of the Centers for Medicare & Medicaid Services (CMS) Documentation Guidelines for Evaluation and Management (E/M) Services. The Marshfield Clinics audit tool and its many derivatives have served as aids to unravel the physician’s cognitive process and application of the guidelines for the selection of an E/M service. Although CMS never officially adopted the audit tool, many of the carriers use the same or similar scoresheets to audit E/M services. The use of scoresheets has prompted many questions concerning the interpretation of the guidelines as they apply to the medical office versus emergency department — particularly, the Medical Decision Making section, under the Number of Diagnoses or Treatment Options, New Problem (to examining physician); additional workup planned. The most recent dispute is the definition of additional workup in the emergency department (ED). The issue may be one of semantics: additional workup planned versus additional workup performed.
These are the two perspectives:
1. Additional workup planned is additional diagnostic evaluation after the ED encounter (i.e., admits, transfers, etc.).
2. Additional workup planned is any diagnostic evaluation in the ED.
It is inferred by No. 1 that since the wording of most score sheets says “additional workup planned,” this describes a problem that cannot be evaluated within the confines of the encounter. The problem with this perspective is that it gives more weight to the office visit than to the emergency encounter. For example, if a new or established patient comes into the office with a new problem, has blood work and returns at a later date, the score sheets allow for four points. However, in the emergency department, since the results of the blood work return during the encounter, the points would not be given for “additional workup.”
The first perspective is considered a conservative approach since some believe counting any diagnostic work-up that occurs in the ED as additional work-up planned will cause encounters to score to a higher E/M level than what may be warranted based on the nature of presenting problem.
The rationale for perspective No. 2 is simply that any diagnostic testing performed after the history and physical constitutes additional workup. This seems to be the most reasonable definition, especially as applied to the emergency encounter. For the emergency department, patients often present with new problems that could be complex and require investigation to make an appropriate medical decision.
CMS states in the 1995 and 1997 guidelines, section “Number of Diagnoses or Management Options,”:
“The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.”
Emphasis has been used to bring attention to the wording of the guidelines, which seem to indicate work-up during the encounter should be considered. To appropriately interpret this section, the question that should be asked is “Was the physician able to make an appropriate decision before the tests were performed?” If the answer is no, then the additional information should be considered when determining the diagnosis/management options. Because of the nature of the emergency room visits, after the test are done the physician returns with new information.
After substantial time researching authoritative sources, it does not appear that there is any official CMS statement or position on this topic. The information found is an “interpretation” or a result of a local Medicare carrier policy and/or negotiation. One source from the American College of Emergency Physicians (ACEP) stated:
“… the ACEP does not have an official position statement on this topic as expressed by a policy statement from the ACEP Board of Directors.” However, it was recommended to “…reserve the additional work-up planned for those patients who will receive additional work-up after the ED encounter.”
Since the guidelines remain ambiguous, you will want to contact your State’s local Medicare carrier to determine if scoresheets are used to audit E/M services and, if so, obtain a copy. If scoresheets are not used, you will want to question them further to clarify, possibly through the Program Integrity office, on how E/M services will be audited or reviewed.
You may find you have an opportunity to influence their determination. In Florida, after discussions between the local Medicare intermediary and member of the Florida College of Emergency Physicians (FCEP), supported by physician opinion, the carrier clarified their emergency medicine audit scoresheet guidelines. They now define “additional workup planned” as, “the ancillary studies that are required in addition to the history and physical examination to rule out or rule in a diagnosis for an undiagnosed new problem.”
Having an authoritative source to stand by your position, especially when you are responsible for helping to defend your organization’s documentation practices, is always key. Whichever perspective you embrace, you should work with your organization to achieve a consensus with your emergency department physicians with regard to the issues presented. With that and your authoritative source documentation, you may be able to convince your local carrier to change a policy if applicable.