ED Coding and Reimbursement Alert

Decision-making isn't based on the diagnosis alone Every patient with a head injury doesn't warrant a level-five evaluation and management (E/M) code - so when the physician's documentation hits your desk, make sure you know how to pick the right level of medical decision-making (MDM).
 
The documentation you need to make the distinction between various levels of MDM isn't always readily available. Not only do you need to know what to look for, but you also need to know when to ask the physician for further clarification.
 
While each of the E/M service levels has minimum requirements, your assignment of those levels calls for more than just adding up elements of the physical exam and history. And watch documentation with a critical eye, because just as every head injury doesn't get a level five, a sore throat can have level-five documentation all over it, but may ultimately score as a level three. Look Closely for All Three Components 1. Number of possible diagnoses or considered management options.
 
Not only should you keep your eyes peeled for the definitive diagnoses, but if a diagnosis is not definitive, make sure your physician has documented pertinent signs and symptoms. If the patient is stable, look for statements telling you whether she has shown improvement or is worsening and whether the doctor has planned a workup. "Most doctors forget to document coexisting or chronic problems that must be considered with the present problem," says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, N.J. 2. Amount and/or complexity of data to be reviewed.
 
"Lots of physicians just document 'labs ordered' or 'labs reviewed' but don't spell out specifics," Brink says. So if you see these phrases, be sure to ask for follow-up information. "Also, they forget to document that they reviewed old medical records or consulted with another physician about the problem - this is sometimes common in the ED," she says, where physicians may be pressured with more immediate matters. 3. Risk of significant complications, morbidity and/or mortality, and comorbidities.
 
CPT's Table of Risk governs this element of the MDM process and consists of three parts:

  Presenting problem, in which the doctor must document whether the patient's condition is stable or  worsening, or whether an undiagnosed new problem occurs (similar to the first element, "number of diagnoses")
  Diagnostic procedures ordered, in which doctors need to spell out what they are ordering - for example, cardiac stress tests or endoscopies - since these tests can affect the overall risk to the patient
  Management options selected, in which the physician specifies what treatment she plans for the patient, such as minor surgery, major surgery, or prescriptions.
 
Remember that the documentation guidelines say you only need two [...]