ED Coding and Reimbursement Alert

Even the most experienced coders are no exception to the rule: Everyone can benefit from continuing E/M education. Read this in-depth analysis on the level-five acuity caveat for advice you may have never heard before. If you're still unclear on when the acuity caveat applies, here's a quick rundown. The acuity caveat allows you, under certain circumstances, to report the ED level-five E/M code (99285) when you don't have complete documentation for the three components normally needed to justify that level: comprehensive history and examination, and medical-decision making of high complexity. When either the patient's mental and physical status precludes documentation or the patient's condition presents an immediate, life-threatening situation, you can exercise the caveat that is, waive the E/M documentation requirements. (To review the acuity caveat reporting basics, see "Guarantee ED Specialists Their Pay With the Acuity Caveat" in the October 2002 ED Coding Alert.) Debunk the 'Admission'Myth If you assume the physician must have admitted the patient to the hospital to exercise the acuity caveat, you're losing out on revenue, says Kim Myers, CCS-P, CPC, president of Emergency Billing Services at www.erbills.com in Lake Milton, Ohio. Some coders may erroneously believe that if patients aren't admitted to the hospital they aren't sick enough to require level-five care, especially if documentation doesn't help you support the E/M level, as would be the case if you exercised the caveat. That assumption may punish your physician for his or her excellent work in stabilizing the patient, she warns.

If the physician performs a high complexity of decision-making on a high-risk patient unable to submit a history and receive a physical, then you have a level-five even if the physician discharges the patient from the ED.

Here's an example of care that warrants 99285 with the acuity caveat even though the physician doesn't admit the patient to the hospital. A minimally verbal nursing-home patient with a history of stroke presents with congestive heart failure (428.0) and is hypoxic, 411.89 (Other acute and subacute forms of ischemic heart disease; other). The physician provides immediate care with intravenous lasix, nitroglycerin and morphine. The doctor cares for the patient until he or she is no longer in distress and is able to return to the nursing home.

The fact that the patient would probably have died if the physician had not acted quickly, plus the work the physician did, justifies assigning 99285, Myers says.

In addition, you should take note that, in this particular case, there was not adequate documentation to support critical care. Educate Physicians Some ED coder policies require specific documentation from the physician to use the caveat to report 99285, and that's one of many reasons why you should educate your physicians about [...]