ED Coding and Reimbursement Alert

ED physicians who dictate charts often struggle to meet HCFAs evaluation and management (E/M) documentation requirements because they usually miss critical elements that support correct coding. Inadequate documentation is the main reason EDs consistently lose out financially in areas such as critical care (99291, 99292), conscious sedation (99141, 99142), foreign body removals (10120*, 10121) and E/M (99281-99285).

Detailed, accurate charting is critical for coding E/M to the highest level. Its also the only way to reflect accurately the physicians efforts an important part of HCFAs E/M level documentation requirements. Heres a costly example: An ED physician spends hours and employs every tool available to save a patients life. After reviewing the documentation, the coder rates the event as an E/M level one (99281). Life-saving, level one! Ask the coder the reason and youll hear something like, The documentations review of systems (ROS) missed several items. If it had been complete, I could have coded the encounter a level five.

Sometimes physicians forget to document elements such as family history and social history, which are difficult to think about in an emergency situation, but are very important when youre coding later on, explains Michele Tabbone, billing/coding coordinator for emergency services at OSF St. Francis Medical Center, a level I trauma center with an ED of 22 attending physicians and 18 residents, in Peoria, Ill. However, the template tells the physician, This is important. This is information I need to code this procedure appropriately.

Templates are also invaluable for coders with little or no clinical background. You can systematically go down the chart and count your ROS when determining your level, Tabbone says. This is a critical area because the number of systems a physician reviews affects directly the E/M code level. In short, template charts prompt for required details and organize documentation of the
patient encounter.

Make Sure Templates Hold Up Under Scrutiny

HCFA considers templates a viable form of documentation. Coders like templates because HCFAs reporting requirements can be incorporated in chart templates, giving physicians what they need to meet each level of service. Templates can be a great teaching tool as well as a prompt, says Bart Hershfield, MD, FACEP, reimbursement committee chairman of the West Virginia chapter of the American College of Emergency Physicians.

The documentation in a template chart will also weather the challenges of an internal or external audit as well as hold up in court. The validity of the documentation that templates contain cant be challenged any more than that of handwritten or dictated charts, Hershfield says.

Even though dictation has been the industry standard for many years, it produces inadequate or incomplete charts, says John Turner, MD, PhD, medical director for [...]