ED Coding and Reimbursement Alert

" The Marshfield Clinic Auditor's Worksheet can help you avoid evaluation and management coding pitfalls, but you have to work around the worksheet's own hidden traps before E/M coding becomes just a walk in the park.

In an effort to curb coding errors, experts designed the Marshfield Clinic Auditor's Worksheet, a tool for simplifying the complex rules for E/M coding. The Marshfield Clinic worksheet is a straight-forward source" " says Kent Moore manager at Health Care Financing and Delivery Systems the American Academy of Family Practices in Leawood Kan. "It is pretty consistent with or faithful to the documentation guidelines for E/M services which it was intended to be as a tool for auditing " he says.

But despite the worksheet's benefits users have expressed difficulties with the point assignments particularly in the number of diagnoses or treatment options portion of the worksheet. Overlooking this portion of the worksheet specifically the "new problem" sections often leads to lost reimbursement for work done by the ED physician or to repetitive denial claims. The Common 'Complexity'Problem:3 Vs.4 Points The "new problem" portion of E/M coding is a "frequent discussion among ED coders " says Todd Thomas CPC CCS-P president of Thomas & Associates a company ensuring reimbursement for emergency physicians in Oklahoma City. Almost all ED patients present new problems to an examiner he says. The two different new problem selections in Grid A of the worksheet's Complexity Section "Number of Diagnoses or Treatment Options" "New Problem (to examiner): no additional workup planned" and "New problem (to examiner): add. workup planned" have different point values. Distinguishing between the two is crucial when it comes to reimbursement for the examining physician.

Deciding whether the service merits three points for "no additional workup planned" or four points for "additional workup planned" is nothing short of a coding challenge Thomas says: "[A]s coders we have to take all the doc's training wisdom and experience and cram it into three points versus four points."

The challenge is whether to assign the ED physician only three points for "no additional workup planned" simply because the ED physician will not do the workup or to give the ED physician four points for examining a patient who will need "additional workup" from someone else. The Solution For example a patient comes in for a fractured metacarpal (815 series) and is given IV morphine for pain control. The emergency physician performs the initial treatment but an orthopedic physician will perform the additional workup. To find the answer look to the definition Marshfield Clinic gives for a "new problem." "New" means new to the examining physician. Because this definition attributes "new" to the examining physician the point value acknowledges all [...]