Inpatient Acuity Sets Bar for Rising ED E/M Levels
By William C. Fiala, MA, CPC, CCS-P, and Nicholas J. Jouriles, MD, FACEP
Research and reporting going back nearly two decades suggests that hospital inpatients are increasingly sicker, and their care more complicated. Intuitively, this greater inpatient acuity should result in higher emergency department (ED) evaluation and management (E/M) service levels for those patients admitted through the ED. This article examines whether that circumstance exists and, if so, how clinicians and coders can use this information to improve coding and compliance.
Inpatient Acuity Is on the Rise
Studies agree that inpatient acuity has been increasing, whether measured against clinical or coding criteria.
In 1986, three years after the introduction of Medicare’s Inpatient Prospective Payment System (IPPS), Bruce Steinwald and Laura A. Dummit reviewed changes in hospital case mix. The results, published in Health Affairs (“Hospital Case-mix Change: Sicker Patients or DRG Creep?” May 1989, 8:p. 35-47), noted that some of the increase in case-mix acuity was a result of better documentation. The review also distinguished changes resulting from “increases attributable to patient need” or “‘real’ case-mix change.”
In part, the so-called “real” case-mix change was the result of less acute cases moving into the outpatient setting, thus leaving higher case weight (higher acuity) cases in the inpatient setting. Cataract cases provide one example (Health Affairs, May 1989, 8:p. 35-47):
“The shift of less complex cases to outpatient settings is particularly noticeable with the treatment of certain illnesses of the eye in DRG 39 (lens procedures). DRG 39 had a weight of approximately 0.57 in 1986, significantly below the average case weight of approximately 1.21. As these patients were moved to the outpatient settings for ambulatory surgery, the overall average DRG weight for inpatients increased. Medical advances have also led to increased acuity among inpatients. The increase in inpatient acuity has been reflected in the DRG coding.”
In a 1996 survey of registered nurses published in the American Journal of Nursing (AJN) (vol. 96, no. 11, p. 25-39), three-fourths of nurses indicated that the acuity of patients assigned to them had risen. Another study published in 2003 (Medical Care, “Licensed Nurse Staffing and Adverse Outcomes in Hospitals,” 41(1):142-152) similarly indicated that acuity increased 21 percent in Pennsylvania hospitals during 1991-1997, as measured by MedQual severity scores.
Many Inpatients Come from the ED
Many inpatients with increasing acuity come through the ED. An analysis of 2003 data by the Agency for Healthcare Research and Quality (AHQR) supports this, concluding, “65 percent of patients admitted on a weekend were initially seen in hospital emergency departments, compared with 44 percent of weekday-admitted patients” (AHRQ News and Numbers, “Patients Admitted to Hospitals on a Weekend Wait for Major Procedures,” March 4, 2010).
MDM as the E/M Service Level Pointer
For outpatient visits by established patients, as well as subsequent hospital care and other visits with established patients, the selection of the E/M code requires two of three key components—history, exam, and medical decision making (MDM)—under American Medical Association’s (AMA) CPT® guidelines. Many coders interpret the discussion on medical necessity in section 1862(a)(1)(A) of the Social Security Act to mean that MDM must be one of the two key components.
For example, consider an article that appeared recently in the American Academy of Family Physicians (AAFP) Family Practice Management Journal titled “Thinking on Paper: Guidelines for Documenting Medical Decision Making.” Authors Robert Edsall and Kent Moore quote Dr. Pat Price, medical director for Medicare Part B in Kansas and Nebraska, as writing, “It should be the complexity of the medical decision making process and the medical problem which is the most heavily weighted factor in determining the E/M service level.”
The AMA has not taken an explicit stand on this issue. The November 2008 CPT® Assistant indicates that the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services are not the AMA’s, but goes on to say:
“…any element of history and examination must be relevant to the care of the patient, not simply serve as documentation to support code selection. Each E/M service states, “evaluation and management of a patient which requires the key components…” [emphasis in original]
This implies history or exam elements should be recorded only to the extent that MDM requires them, which may be another way of saying MDM is always a required key component.
ED E/M codes require three of three key components to assign a service level. Based on the aforementioned information, when you determine the level of service, MDM should be the pointer.
MDM’s Influence on Level of Service
Because acuity among inpatients is increasing, and significant number of inpatients are coming through the ED, you can reasonably expect that ED patients who are admitted should have higher levels of E/M codes assigned, and that the validity of the coding can be tested by looking at MDM. Said differently, the assigned ED E/M code should be at a higher level (99285 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity or 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)—and if it’s not, MDM should be checked to see if the original code was assigned as a result of error or documentation deficiency.
Put the Numbers to the Test
ED encounters at a 511-bed, 26-bassinet, adult, tertiary-care, not-for-profit, teaching hospital with 56,507 ED visits at its main facility ED were selected from three days in November 2009. Review of the coders’ posting logs identified patients who were admitted.
The facility admitted 16,381 cases from the ED in 2009; the three days’ ED admissions represent approximately 0.8 percent of all 2009 admissions from this department. Coding for those encounters was reviewed using 1995 guidelines supplemented by the Iowa Medical Society form (version 010198). This form has been used by the Ohio State Medical Association (OSMA) for its chart auditing training classes. Certified Professional Coders (CPCs®) completed the initial coding; a certified coder also completed the review.
On the first day examined, 40 patients were admitted. Of those, 37 were initially coded with either 99285 or 99291; 93 percent of the admissions were initially coded with an E/M code reflecting high complexity MDM and/or critical care. Review coding confirmed the initial coding. Of the three remaining encounters, one was not coded due to a lack of documentation at the time of the review. The remaining two were originally coded 99284 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity, reflecting moderate complexity MDM.
On the second day, 50 patients were admitted. Of those, 31 were assigned either 99285 or 99291; 62 percent of the admissions were initially coded with an E/M code reflecting high complexity MDM and/or critical care. Of the 19 remaining encounters, two were not coded at this facility because they were transferred from freestanding EDs to be admitted through the main ED. One was not coded due to a lack of documentation at the time of the review. Among the remaining 16 encounters, 12 had circumstances that pointed to high complexity MDM (see Chart A), but level of service coding was limited due to incomplete review of systems (ROS).
Exam documentation limited the level of service in another encounter, where the circumstances of the encounter pointed towards a higher level of service (see Chart A). Three of the four remaining encounters did not rise above moderate complexity MDM. The last encounter was review coded at 99285, one level higher than initially coded. The original coding for all other encounters was review coded consistent with the initial coding. Adjusting for documentation deficiencies and review coding, 88 percent of admitted patients on day two were (or should have been) coded with either 99285 or 99291 when MDM was used as the pointer to level of service.
On day three, 34 patients were admitted. Of those, 28 were coded with either 99285 or 99291; 82 percent of the admissions were initially coded with an E/M code reflecting high complexity MDM and/or critical care. Of the six remaining encounters, two were not coded at this facility because they were transferred in from freestanding EDs, as they could not be admitted through the main ED. On review of the remaining four, one was found to be appropriately coded 99284. Three had circumstances pointing to high complexity MDM (see Chart A), but level of service coding was limited due to an incomplete ROS. Adjusting for documentation deficiencies and review coding, 91 percent of day three’s admitted patients were, or should have been, coded with either 99285 or 99291 when MDM was used as the pointer to level of service.
Use the Correlation to Resolve Documentation Deficiencies
With a 90.3 percent overall rate, the modest sample of encounters reviewed clearly suggests that when MDM points to the level of ED E/M service among patients subsequently admitted to the hospital, that level will be higher. This conclusion is intuitively reasonable, since the studies reporting shows the acuity of admitted patients—measured by both coding and clinical measures—has been increasing.
ED compliance staff may want to examine level of service distributions of treated and released patients separately from those of admitted patients. Although this sample suggests higher levels of ED E/M codes are appropriate for these patients, it does NOT mean all admitted patients should be coded with the higher levels of service. It means clinical staff should be aware of this suggestion and document appropriately, consistent with their facility’s compliance guidelines. Coding staff should also know this, and help clinical staff to resolve documentation deficiencies.
William C. Fiala, MA, CPC, CCS-P, is an instructor for the University of Akron’s Allied Health Department. Beyond the university setting, his company, Fiala Analytical Services, Inc., assists clients with audits and compliance issues.
Nicholas J. Jouriles, MD, FACEP, is an academic emergency physician and is professor and chair of emergency medicine at Northeast Ohio Medical University. Dr. Jouriles is also a past president of ACEP.
Editor’s note: An expanded version of this article, complete with footnoted references, is available by contacting John Verhovshek, MA, CPC, at firstname.lastname@example.org.