ED Coding and Reimbursement Alert

When the heart is weak, report high-level E/M confidently

Chest pain is always an emergency, regardless of the patient's final diagnosis. Solve this case study and see if you know what to report when push comes to shove with a patient's heart.

Physician's documentation

Presenting complaint: Chest pain

History of present illness: 44 yo otherwise healthy male with no prior history of CP presents with intermittent episodes of substernal chest pressure, 5/10 severity, lasting up to 5 minutes throughout the day. Worse with movement or inspiration. No diaphoresis or SOB. Family history of CAD. No pain right now; took aspirin at home. Is a smoker. Past appendectomy.

Review of systems: (as per HPI) Full ROS otherwise (-)

Physical examination:
Alert VS reviewed BP 150/90 HEENT: (-)
Chest Clear  
Cor: RRR No murmur    
Abdomen: No tenderness or masses
Extremities: No swelling, edema, or rashes   
Neuro: No focal abnormalities

ED course of treatment: IV, 02, maintained on monitor. EKG Interpretation: study done for chest pain. NSR rate 84 nonspecific lateral changes, intervals normal. No prior tracings for comparison. Initial myoglobin and troponin (-). Continued to be pain-free throughout stay.

Disposition: Discussed with his PCP. Patient is an appropriate candidate for transfer to observation. Talked with our physician in the observation area and wrote orders for transfer.

ED diagnosis: Acute chest pain - evaluation for possible acute coronary syndrome.  10 pm: Admit to observation for evaluation of chest pain.

Observation note: Patient received from my partner in ED. Discussed case; reviewed studies. Agree with H&P. Will do serial cardiac enzymes and EKGs to evaluate for acute coronary syndrome. Patient on monitor. Repeat myoglobin and troponin; still nondiagnostic. 2nd EKG unchanged. At 0400 hours on the 16th he had recurrent pain. Evaluated him then and did 3rd EKG. Tracing showed a rate of 84 with NSR with ST segment elevation in leads 1, aVL, V5-6, consistent with lateral ischemia. Gave SL NTG and started on drip. Discussed with cardiology; he's going to cath lab. Given Integrilin and Atenolol before leaving observation. Will be admitted to hospital after cath lab.

Discharge summary: Patient to observation, where repeat EKG showed ST elevation consistent with acute MI.

Disposition: Cath lab followed by inpatient admission.

Diagnosis: Acute lateral MI.

Note: The same group runs the emergency department (ED) and the observation unit, and the ED doctor admitted the patient to his primary medical doctor the day after he presented to the ED.



Choose 1 Code for 2 Same-Group Physicians

Many payers will consider the services provided by members of the same group and specialty to be of the same provider. When this is the case, you should report only the more comprehensive evaluation and management code. With this patient, that code is from the observation series: 99220 (Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: comprehensive history, comprehensive examination, and medical decision-making of high complexity). And you could add code 99217 (Observation care discharge day management) to represent the discharge services.

Find Complete Review to Unlock Correct Code

You know the E/M code for this patient should be 99220. But you're not sure whether you've got a comprehensive physical exam - which you need, as outlined in the 1995 documentation guidelines, to satisfy the requirements for a comprehensive service. Here's how to break it down.

Based on the physician's documentation, you can derive these eight systems for the E/M, says Sandra Pinckney, CPC, coding supervisor at Certified Emergency Medicine Specialists in Grand Rapids, Mich.: Constitutional ("alert"), eyes (negative), ear/nose/throat (ENT) (negative), respiratory ("chest clear"), cardiovascular ("RRR no murmur"), gastrointestinal ("no tenderness or masses"), integumentary ("no rashes"), and neurological ("no focal abnormalities").

Hint: When you see "HEENT" in the physician's notes (head, eyes, ear, nose and throat), remember that while physicians often document these body parts together, they're not all the same system, says Kimberly Engel, coder at Infinity Healthcare SC in Mequon, Wisc. "Eyes are part of a separate system from ENT," Engel says. And you could also consider "head" as part of the neurological or musculoskeletal systems, which were already separately satisfied.

Report Final Diagnosis and Symptom

You'll also need to assign 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for the physician's interpretation of the EKG, says Cindy Morgensen, CPC, CCP, claims manager of managed care at Wenatchee Valley Medical Center in Wenatchee, Wash.

In this case, the patient had two EKGs that were well-documented, and you certainly want to get credit for them both. Correct coding and Medicare guidelines would suggest using modifier -76 (Repeat procedure by same physician) or -77 (Repeat procedure by another physician) when the physician performs multiple EKGs. There are great regional payer variances in this area, however. Some carriers request that you append no modifiers, and others will only pay when you've appended modifier -59 (Distinct procedural service), so you should check with the individual carrier before submitting this claim.

For the diagnoses, you should report both 410.51(Acute myocardial infarction of other lateral wall, initial episode of care) and 786.51 (Precordial chest pain) to give the clearest picture of why the physician treated the patient as he did.