ED Coding and Reimbursement Alert

Plug your documentation gaps
                                                                               
Coding for patients with life-threatening illnesses and injuries can require less stringent evaluation and management (E/M) documentation than for more stable patients. But the documentation waiver contained in 99285 can wreak havoc with your reimbursement if you don't know how to handle the paradox of documenting elusive services.

Don't Count On Getting the Whole Picture

For a severely ill patient, extenuating circumstances may prevent emergency physicians and staff from collecting the complete data required to submit 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a comprehensive history, a comprehensive examination, and medical decision making of high complexity). But the level-five acuity caveat provides a way both to deliver timely treatment and to recover appropriate reimbursement, even if some of the information required by documentation guidelines is missing from the medical record. Here's the catch: The caveat only works if both the physician and coders document why they need it.

When you report 99285, the acuity - or level-five - caveat waives the requirement for complete documentation, including a comprehensive history, and/or comprehensive examination.

Rise to the Challenge With Incapacitated Patients

Because E/M documentation depends on patient participation, incapacitated or limited patients create a documentary hole - a hole that you have to justify in order to receive reimbursement. "In the physician's documentation, you must see a notation that says, 'The patient - or the patient's family - is unable to give us the information that we need' " telling you that the patient was incapacitated or otherwise unable to communicate, says Barbara Steiner, RN, RHIT, emergency room coding coordinator at Northeast Medical Center in Concord, N.C.
 
Caring for patients who are mentally incapacitated or in critical condition requires substantial resources, Steiner says. So when the doctor has obviously done this difficult work, "You should at least get a level five for the critical care of those patients," Steiner says. And the acuity caveat is the only way to get paid for this work.
 
You'll have to make sure you have documentation of the physical exam, Steiner says. As for the rest of the basic patient information, "You can either get it from family if they're [nearby], or if the patient's from a nursing home, call the nursing home," she says. If the person has been a patient at the hospital before, request old medical records. Or, if someone knows that the patient has received treatment at a different hospital, obtain the records from there.
 
"Usually in the ER, older patients who can't give information come from a nursing home. If it's an accident patient, the best thing you can do is go by what EMS found," Steiner says. "And just put in the documentation, 'Unable to supply current information.' " Ultimately, you do the best you can - but you absolutely must have that statement in the record, she says.
 
For example, a common clinical scenario seen in the ED is an elderly patient with pneumonia or a urinary tract infection with early sepsis, who presents by ambulance without any family. Often family and friends are absent, and if the patient doesn't live in the area, you'll need at least a day to get contacts. The patient has an altered mental status, and his evolving sepsis requires prompt clinical attention even though the conditions prevent the doctor from performing a complete history and physical.

Apply Caveat Only to Level-5 Patients

Just because a patient can't give you the information necessary for a complete history and physical doesn't mean the acuity caveat applies. For example, every young child who presents in the ED doesn't require level-five service, says Jeff Linzer, MD, MICP, FAAP, assistant professor of pediatrics in the division of emergency medicine at Emory University School of Medicine in Atlanta. A 3-year-old who presents with the flu cannot explain her symptoms or history to the physician, and her parents may be unavailable to answer such questions, but this patient doesn't meet acuity caveat requirements because flu treatment isn't a level-five service. "The risk drive factors are not always there," Linzer says.
 
On the other hand, "An adolescent or an adult who is unable to tell you his history because of a head injury or a stroke will meet a level-five test because the severity's already there," Linzer says. So even if the person could give you full details on his history and current problem, hia condition qualifies him for level-five treatment.