ED Coding and Reimbursement Alert

Question: How should we code E/M in the ED if we are unable to obtain a patient's history?

Maine Subscriber
 
 Answer: E/M services 99281-99285 (new or established patient) and 99291-99292 (critical care) provided in the ED require three key components: a problem-focused history; a problem-focused examination; and medical decision-making of low, moderate or high complexity. An ED physician unable to report a patient's history must document the condition and/or circumstances that precluded the history. Some patients might be too ill to speak, uncooperative or unconscious, or they're at high risk unless treated immediately. This is called "the emergency caveat." Documentation of these circumstances qualifies as a comprehensive history. For example, the ED physician must clearly indicate that he or she needed to act quickly to prevent deterioration of the patient's status. Documentation must be specific.
 
The ED doctor must also state specifically the source of the documented history, such as information from the emergency medical service (EMS) or nursing-home staff. The physician must also indicate that other sources for history were unavailable. The five recognized sources for emergency history include the family, nursing-home staff/records, prior hospital charts, EMS or a personal physician. The physician must cite at least one in the chart.