ED Coding and Reimbursement Alert

Here's how to make smart choices about HPI, MDM

Diagnostic tests, HPI elements, and radiologic review can all make choosing the correct E/M level difficult in the ED. If you-re having trouble deciding what credit these services should receive, check out this expert advice on tough E/M questions. Collect Credit for Diagnostic Decisions Question: Suppose a physician orders a diagnostic test, such as an electrocardiogram (EKG), but the patient refuses to undergo the test. Should the physician still get credit for the order when determining the complexity level associated with the encounter?

Answer: You should factor the physician's order into the medical decision-making or care/treatment plan. Be sure you document that the physician ordered the test, the patient refused it and why he did so.

What you should know: Your physician's decision to order a diagnostic test can impact each of the complexity (medical decision-making) section's three elements, says Jim Collins, CPC, ACS-CA, CHCC, CEO of the Cardiology Coalition in Matthews, N.C. Physicians frequently recommend a test, but the patient declines for various reasons (for example, financial concerns or reservations about risks). Give the Physician Credit Factoring in the physician's order makes sense, because if the physician -went through the medical decision-making process to determine that the patient needed a particular test, even though the patient didn't follow through, the physician ... should receive credit for that, provided there is documentation of that thought process,- says Sherry Wilkerson, RHIT, CCS, CCS-P, manager of coding and compliance for CHAN Healthcare Auditors in St. Louis.

Example: A patient with a history of migraine presents to the emergency department with a headache that is worse than her usual pattern. The ED physician orders pain medication and a computed tomography (CT) scan of the head due to the atypical severity of the patient's headache.

After receiving the pain medication, the patient declines the head CT, stating that she feels much better. The physician urges the patient to go through with the CT scan and documents appropriate clinical and medical legal support for his concerns. Ultimately, the patient still refuses the test.

Even though the patient did not undergo the study, the physician's documentation reflects his higher level of concern, and that should be factored into the medical decision-making. Don't Dismiss HPI Elements Question: A patient presents with shortness of breath. The physician documents that -the patient's chief complaint is shortness of breath, which is not exacerbated with any specific activity and has no reported associated symptoms.- Should the physician receive credit for documenting the history of present illness (HPI) elements of -modifying factors- and -associated signs or symptoms,- even though he reported that no activity exacerbates the condition and no associated signs or symptoms exist?

Answer: The [...]