ED Coding and Reimbursement Alert

Here's how to make economic choices with E/M documentation Elements from the physician's review of systems (ROS) and history of present illness (HPI) documentation can work harder than many coders make them. Here's how to ensure you-re not wasting valuable time querying the physician--or losing reimbursement through downcoding--by using the available information wisely. Section Categories Aren't Holy While some coders adhere religiously to drawing ROS elements from the ROS section in the chart and HPI elements from the HPI section, there's no prohibition against mixing and matching. In fact, when you-re short on information from one section, it may behoove you to nab an element from another section to satisfy the E/M level that best represents the physician's work.

For example, if the emergency department physician documents a contributing complaint in the HPI, you can use that information to meet the appropriate number of systems in the ROS--the doctor doesn't need to document the same information in both the HPI and ROS sections.

-According to CMS, where you get the information in the chart means nothing--you should use the entire dictation for your information,- says Kevin Arnold, CPC, medical coding instructor and outpatient coder at Danbury Hospital in Danbury, Conn. -A common mistake among coders is to compartmentalize into the section that the heading puts it into. What we are supposed to do is determine where it belongs by the context of the statement (for example, HPI, ROS, or PE)--the statement will tell you where it belongs.-

Any item can count for both the HPI and the ROS, Arnold says. However, you cannot count it twice for two items within the same category. For instance, you cannot use the same item for -quality- and then -severity- in the HPI. Beware of Payer Quirks You-ll find documentation from CMS available on the American College of Emergency Physicians (ACEP) web site at www.acep.org confirming that the doctor doesn't have to list an element twice for you to use it twice. But despite concrete, written confirmation, payers still love this myth. Depending on where you-re located and which carrier you-re billing, you may or may not face difficulty in getting these claims paid.

In Texas, for example, you cannot use a single piece of documentation to receive credit in two different subsections of the E/M service, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Deer Park, Ill. The Texas medical director has stated in no uncertain terms that she gives no credence to the letters written by the Noridian medical director, nor to the one written by CMS in regards to using the same element for HPI and ROS. -While we would like to think that the interpretation of the documentation [...]