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.)

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.

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 this coding concept.

Check to see if your department has a policy on the issue. "We require our physicians to specifically state, 'The information could not be obtained due to the condition,'" says Cheryl Klarkowski, RHIT, working for Baycare Health Systems, a management services organization serving the Green Bay, Wis., area. Sufficient documentation might state, "Review of systems was unobtainable due to the severity of the patient's condition," in which case you could apply the caveat, she adds.

Even if your department doesn't have a policy, let your physicians know that the more explicitly they state the reasons for not obtaining E/M components, the more likely you will apply the caveat with success.

On the flip side, educate your physicians about when the acuity caveat damages their revenue. Code 99285 and critical care are very close in nature. In fact, a good way to think of the caveat is that it allows you to report critical care under the 30-minute mark, Myers says. To apply critical care codes (99291 and 99292), the physician must document that he or she provided care to a critically ill or injured patient that lasted at least 30 continuous or discontinuous minutes, Myers says. Given this requirement, you may sometimes have to apply the caveat to a critical care case and use 99285 because the physician didn't document critical care and the time spent.

Tell your physicians that if they provide critical care, they must document their total time spent use start and stop times to be extra safe and what they did during that time, Myers says. Bring cases you had to downcode from critical care to the level-five E/M caveat to your physicians to help them improve their documentation, she says.

If your department doesn't require your physician explicitly to document caveat circumstances, you have to learn to read between the documentation lines.

There's no clear-cut criterion in CPT or Medicare policy, such as hospital admission or diagnosis set, for determining when to use the caveat, so you need to pay attention to documentation details that flag a level-five acuity case. Don't determine your E/M level by simply counting the E/M bullets in the documentation, in which case you may inappropriately downcode your claims, Myers says.

Look out, instead, for physician documentation that indicates high-risk patients and high-level care. Here are some typical indications of a case to which you should apply the caveat, Myers says: