Medicare Compliance & Reimbursement

Physicians' emergency department visits could be under more security soon.

A recent survey by the American Hospital Directory showed that evaluation & management (E/M) levels reported in the ED have increased in the past few years. For example, 24 percent of visits were level four in 2004, compared with only 20 percent in 2002. Experts offer physicians two key tips for dealing with ED E/M audits:

1. Make sure that any auditor understands ED coding. There are a few important differences between E/M services in the ED and elsewhere, says David McKenzie, CAE, director of reimbursement with the American College of Emergency Physicians. For one thing, there's no distinction between new and existing patients in the ED.

For another, coders should choose the level of service in the ED based on the presenting problem, not the final diagnosis. For example, if a patient shows up with chest pain, shortness of breath and a family history of heart disease, the ED doctor has to assume it's a heart attack and act accordingly--even if it turns out the patient forgot to mention he ate seven spicy burritos, McKenzie says. It may take a while for lab tests to come back, and meanwhile the ED physician goes by what the patient reported and the symptoms noted on arrival.

2. Look for "red flags" in E/M documentation. These may include "cloned" documentation that has no individuality, says Sandra Soerries, director of coding and compliance with Department B in Kansas City, MO. Coders must check that their doctors aren't using the same diagnosis codes for every patient. If coders have an E/M documentation template, they must make sure that the physicians are using it properly--if they're using it at all.

There are a few reasons why E/M levels could be increasing somewhat in the ED, Soerries says. For one, more emergency physicians may be coding correctly as they rely on templates and electronic health records. "We are coding more accurately than we did in 2002," she says.