ED Coding and Reimbursement Alert

One of the most common challenges to the ED coder is identifying the correct evaluation and management (E/M) level of service for an ED visit, and determining the correct modifiers to apply to that code when E/M services are performed in addition to procedures. This months case provides an opportunity to explore the multiple options available to the coder when differentiating a procedure service from an E/M service. In addition, it offers a challenge to the coder in correctly identifying the level of E/M service provided, as well as determining the level of repair performed by the emergency physician. (Please see the box on page 22 for the patient chart information that was available to coders in this case.)

Determining Level of Service

The presentation of this patient via ambulance and immobilized on a backboard provides the first clue that a potentially serious injury may have occurred. In addition to the obvious laceration to the face, the patient is complaining of syncope, which requires further investigation by the emergency physician.

From the coding perspective, it is always beneficial for the physician to address each component of the patients history separately so that the coder can easily select needed elements to justify a particular level of service.

Although components of the history are combined in this example, the elements are clearly identified. The coder must review the entire history narrative and attempt to differentiate the elements of each history component.

Note: When selecting documented elements of the history to justify a level of service, there can be some swapping of terms where they apply to the history of present illness (HPI), past medical history and review of systems (ROS). There remains, however, much controversy over the use of a given element for more than one history component. For example, weak and nauseated could qualify as an element for both the HPI and a gastrointestinal ROS. Common sense tells us the statement could be used for both. However, in the past few years, numerous statements have been made by HCFA representatives in private correspondence and public comments that references may only be counted as an element once. Thus, if the claim is reviewed by a carrier or private payer, it would not be unusual to see a term allocated to only one element, either the HPI or the ROS.

Scoring HPI

The following elements of the HPI were identified: location (nose and forehead); associated signs and symptoms (neck pain, weak, nauseated); context (lost balance while cleaning hot tub); duration (this afternoon, undetermined duration).

Level of HPI: Extended.

Scoring ROS

A review of systems is generally considered to be an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms the patient [...]