EM Coding Alert

Coding emergency department (ED) encounters can be pretty complicated because of all the balls at play: diagnostic tests, history of present illness (HPI) elements, and radiologic reviews, just to name a handful.

Check out these three scenarios to get a better idea of how to navigate three common ED coding questions.

FAQ 1: Do you count tests ordered, even if they were not performed?

Question: Suppose a physician orders a diagnostic test, such as an electrocardiogram (EKG), but the patient refuses to undergo the test. Should the physician still get credit for the order when determining the complexity level associated with the encounter?

Answer: You should factor the physician’s order into the medical decision making (MDM) or care/ treatment plan. Be sure that someone documents the fact that the physician ordered the test, but the patient refused it. If possible, you should also record why the patient refused the test.

What you should know: Your physician’s decision to order a diagnostic test can impact each of the complexity (medical decision making) section’s three elements. Physicians frequently recommend a test, but the patient declines for various reasons (for example, financial concerns or reservations about risks).

Factoring in the physician’s order makes sense, because if the physician went through the MDM process to determine that the patient needed a particular test, even though the patient didn’t follow through, the physician should receive credit for that, provided there is documentation of that thought process.

Example: A patient with a history of migraine presents to the ED with a headache that is worse than their usual pattern. The ED physician orders pain medication and a computed tomography (CT) scan of the head due to the atypical severity of the patient’s headache.

After receiving the pain medication, the patient declines the head CT, stating that they feel much better and just wants to go home. The physician urges the patient to go through with the CT scan and documents appropriate clinical and medical legal support for their concerns. Ultimately, the patient still refuses to undergo the test.

Even though the patient did not present for the study, the physician’s documentation reflects a higher level of concern, and that should be factored into the MDM.

FAQ 2: How do you count HPI documentation?

Question: A patient presents to the ED with shortness of breath. The physician documents that “the patient’s chief complaint is shortness of breath, which is not exacerbated with any specific activity and has no reported associated symptoms.” Should the physician receive credit for documenting the HPI elements of modifying factors and associated signs or symptoms, even though the physician reported that no activity exacerbates the condition and no associated signs or symptoms exist?

Answer: The physician deserves to receive credit in this scenario. They provided valuable information that they gathered for a medically necessary reason, and as long as it’s documented in the patient’s medical record, it deserves to be counted.

Quick tip: Ideally, the physician would simply document that the patient’s HPI is negative. Instead, if the patient has no exacerbating activities or associated symptoms, as in the above example, the physician should put that in the documentation.

For example, in the documentation, the physician might write, “The patient relays that their problems are not related to time of day, they relay no aggravating or alleviating factors, and there are no associated symptoms.”

The bottom line: With this simple sentence, the physician would document three of the required four HPI elements (timing, modifying factors, and associated signs and symptoms) necessary to establish an extended HPI. Noting which elements are negative rather than saying “HPI negative” will show your payers the exact work that the physician did gathering the information.

FAQ 3: Can these two elements constitute a moderate-risk service?

Question: A patient presents to the ED for a tetanus shot. Another physician had already examined her injury — a puncture from a can that she was opening. The ED physician documents a very brief exam of the wound and orders a tetanus shot. Can this visit count as a moderate-risk service, due to the intramuscular injection and the potential for adverse reaction?

Answer: If you refer to the clinical examples section of the CPT^® manual under code 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a problem focused history, a problem focused examination, straightforward medical decision making), one of the samples reads: “Emergency department visit for a patient for tetanus toxoid immunization.” So while your assessment of the moderate risk associated with this scenario may be correct, you should continue to consider low-level evaluation and management (E/M) services for these situations (usually 99281) if the patient has only a cursory interaction with the ED physician and has been pre-screened by another provider.

If the ED physician is seeing the patient for the first time, evaluating a traumatic injury, and addressing the mechanism and the potential complications, then a higher EM code may be appropriate, depending on the documentation and the medical necessity driving the visit.