Good Faith Effort Warrants Level 5 E/M

A level 5 evaluation and management (E/M) visit in the emergency department (ED) requires a comprehensive history and exam and high-complexity medical decision making (MDM). Getting all three components in an ED isn’t always possible, however.
For example, the physician may not be able to obtain a history of present illness (HPI) because the patient is unresponsive. Or the physician may not be able to perform a comprehensive exam because the patient is uncooperative.
In cases such as these, you might assume you have to downcode the encounter to a lesser ED visit. Not necessarily, reports ED Coding Alert.

There’s always an exception to every rule. Case in point: the ED caveat.
If you invoke the ED caveat, you might be able to report 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function even though the physician wasn’t able to fulfill all three key components.
“The caveat is a CPT exception unique to emergency medicine 99285 services. It provides an exception to the E/M content requirements when the physician is unable to obtain the required information,” explains Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La. to ED Coding Alert.
According to an ERcoder discussion board: “In 1997 ACEP asked AMA about the inability to do a history or comprehensive exam. AMA forwarded the question to Dr McCann who replied with ‘in those circumstance where the patient’s nature of illness/injury does not lend itself to doing eliciting a history nor is it available from either a SNIF or other hospital transfer sheet, the patient, family, significant other or other source, or doing a comprehensive examination, the physician should document in the medical record the circumstances which precluded obtaining this information or from doing the comprehensive examination. This shows a good faith effort on the part of the physician.’”
ED Coding Alert suggests some terms that could indicate a caveat if they appear in the notes, such as:

• history unobtainable
• history obtained by family member due to altered mental status

Additional documented terms a coder can look for that might indicate a patient was unable to fully communicate, says Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass., include:

• unresponsive
• obtunded
• comatose
• aphasic
• paralyzed and intubated
• incoherent due to intoxication or drugs

ERcoder warns: “However there are times when these patients do not have high MDM and high severity NOPP and it would not be appropriate to code 99285 just because the Hx or exam was limited. A patient from the nursing home that has decreased LOC but that is normal for them and has not had a recent change in LOC but has cloudy urine would not be a 99285 just because the Hx is unavailable.”
Medicare contractors may also have a difference of opinion regarding the ED caveat. As a rule, you should first confirm your payer’s policy before applying the ED caveat—no exceptions.

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