Coding E/M in the ED, Part 2
Questions about 2023 evaluation and management guidelines in the emergency department, answered.
AAPC’s HEALTHCON, May 21-24, offered several sessions on the subject of evaluation and management (E/M) coding, including “Emergency Department Professional Fee E/M Coding,” presented by Raemarie Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, AAPC Approved Instructor, AAPC chief product officer.
In this session, Jimenez reviewed the 2023 E/M guidelines as they apply in the emergency department (ED) and clarified certain known misconceptions. But the guidelines are just that, guidelines, and attendees still had questions.
Questions From the Audience
Several questions came out of Jimenez’s discussion on documentation challenges for independent historians and discussions with other providers.
Q: Do all pediatric patients automatically qualify for an independent historian?
Rae: It depends on what the parent’s information is and the age of the patient but, yes, if the parent provides their own observations and information, then it is an independent historian because the patient can’t verbalize what’s going on and the parent just knows what they have observed, so the provider has limited information.
Q: If information in the medical record just says “historian,” can the provider get credit for it?
Rae: Yes, if you know that it was a parent that came into the ED with the patient and provided that information, then you could count it toward medical decision making.
Q: What’s the age cutoff for pediatric independence?
Rae: There is no age cutoff. If the parents are giving the information, the age of the patient doesn’t matter.
Q: We have providers counting independent historian when the patient is a child and there is no documentation to support that the history was actually obtained from the parent. Do we just assume?
Rae: No, you don’t assume. You need to know what information was obtained from the parents, or independent historian.
Q: If it’s a 2-year-old patient and there is a history of present illness (HPI), clearly, they got the HPI from somebody other than the patient. Is that inferred that it came from the parent?
Rae: No, you want to know where the HPI came from. It could be information from the emergency medical technician who brought the patient into the ED. It could be the parent. It could be a teacher. You need to know where the providers are getting the information.
Q: Does independent historian include translations?
Rae: No. A translation is not the translator’s observations of the patient. It’s what the patient would have said if they could communicate on their own.
Q: What if the provider reads another provider’s note. Is that a discussion?
Rae: No, they have to have two-way communication with each other for it to be a discussion. And it can only be counted once. So, if the provider talks to the other provider a couple of times, it only counts as one data element.
Q: If a provider reaches out to another provider for discussion about a patient, but they do not reach that provider on the day of the encounter, does it count?
Rae: That is included in the guidance: If the provider attempts to reach out to another provider for a discussion, even if it is a failed attempt, it counts. The discussion might happen later and then the provider has to go back and addend their note.
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