ED Coding and Reimbursement Alert

It’s important to get a feel for whether your ED is reporting 99281 appropriately or being forced to downcode to 99281 because documentation isn’t thorough enough, which can happen to even the most seasoned documenters.

“I’ll be reading a note and I’ll know a doctor had to review something in order to come to a conclusion but it isn’t documented,” says Deena Wojtkowski, CPC, CEMC, CCP, vice president of client services with ebix, Inc. “Whereas new doctors know they need to be documented, seasoned doctors may not write it down because it comes so naturally to them, but because they do it every day and it’s normal for them to not document those specifics and I talk about that all the time. I’ll say, ‘I know you’re asking these questions, put it in the documentation. There doesn’t have to be a lot documented to meet the required elements, but it has to be there. Don’t simplify the documentation, it doesn’t mean you have to document paragraphs.’”

Check the Documentation Requirements

For 99281, the requirements do not vary substantially between the 1995 and 1997 versions of the E/M documentation guidelines.

In both versions, documentation of the problem-focused history must include the chief complaint (CC) and a brief history of the present illness (HPI), with at least one element identified (e.g., a rash of two days duration, uncomplicated injury from a minor puncture wound, etc.). In neither version is review of systems (ROS) or past medical, family or social history (PFSH) required.

A problem-focused physical exam is the second requirement of a level 1 E/M service, and requires documentation of the exam of only one body area or system. The 1995 Documentation Guidelines for 99281 state that the examination of at least one body area/organ system must be documented. The 1997 Documentation Guidelines indicate that the exam documentation should include at least one element identified by a bullet in one or more organ systems or body areas.

The third component of a level 1 service is medical decision making (MDM) of straightforward complexity. According to CPT^® guidelines, straightforward means that:

1. There is a minimal number (1-5) of diagnosis options considered.

Example: Ant bites to the arm cause a rash; a minor puncture wound means the patient needs a tetanus prophylaxis. At this level, the diagnosis is usually obvious and does not require substantial differential diagnoses.

2. None or a minimal amount of medical records, diagnostic test results, and/or information obtained, reviewed, and analyzed.

Example: No review of medical records data or diagnostic test results to diagnose a rash caused by ant bites or a tetanus shot for recent puncture wound.

3. Minimal risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient’s presenting problems, the diagnostic procedures ordered, and/or any management options considered.

Example: Ant bites and minor puncture wounds are low-risk presenting problems. Diagnostic procedures, if ordered, are of low risk (i.e., an EKG, dipstick urinalysis, chest X-ray, venipuncture). Management options that would be considered minimal include orders for the patient to rest, gargle with medication, or application of superficial dressing.

Must the Physician See the Patient?

Clinically, a patient can be treated by a nonphysician provider (NPP), such as a physician assistant, nurse practitioner, etc., independently of the attending physician, although that physician supervises the practitioner. In these cases, either the physician or a nonphysician provider would see the patient and render treatment.

However, Medicare does not recognize the concept of incident to services in the hospital setting. So, if the NPP provider provides the care to the patient, they must bill the code 99281 to Medicare using their own NPI and will collect at 85 percent of the physician’s fee schedule amount.