Wiki E&M level coding

[LTibbetts]

I'm sure this has been addressed in the past but I am curious about ER admit codes and what qualifies for a level 4 or 5. I have providers here that tell me that an ER admit has to be either a level 4 or a level 5, based solely on the fact that the patient was admitted. Is this true?

Also, for the ROS, I keep getting conflicting info so I could use some clarification on this. I have read the guidelines over and over and just can't seem to grasp it. I come across many charts that state the ROS is as per HPI. Does this count and if so, can you count the info from the HPI again for the ROS?

And lastly, for critical care codes, I know that the CPT book clarifies some of the tests that are inclusive to cc codes, but are there more things included in the cc codes that aren't listed there? Like the intubation for instance, the gastric is included, does that mean that an ET tube is not? What if you have a chart and it specifies that the doc spent 40 minutes providing critical care minus the time that it took for the other procedures performed. How do we know how long it took to do a certain procedure? How are we suppose to calculate that?

 

[FTessaBartels]

It would help to divide you questions

Leslie,
It would help to divide this into three separate threads.

My responses, as always, are specifically applied to coding for the professional fees ONLY.

ER ADMIT CODES - there is no such thing. Are you talking about ER codes or Initial Hospital Visit codes? If service is provided in the ER to a patient who is then admitted to the hospital by the same physician who provided the ER service, then only the Initial Hospital Visit should be coded - The documentation will determine the level of the code.

ROS vs HPI - If the ROS documentation reads: Full 14-system ROS performed and negative other than HPI - then I would count it. BUT beware -- you need to check with your local carrier as to what language they will accept on the ROS. More and more are requiring that each system be outlined individually. If it just says "ROS as per HPI" then I will count only what I don't need for HPI elements from the HPI paragraph as ROS. A lot of doctors lump everything in the history section into one big paragraph and the coder needs to sift through to find and apply the information where needed.

CRITICAL CARE - if the documentation says "40 minutes minus procedures" then you CANNOT tell how much time was spent in critical care, so you cannot code critical care. If the documentation says "40 minutes exclusive of procedures" then you know that 40 minutes was spent in critical care.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[MRKOCUREK]

E&M Level Coding

I have to respectfully disagree with your information FTessabartles. You stated that the er admit would be included with the IP. Please be sure to read your 72 Hour Rule. If it is non-diagnostic, and there is not an exact match between the diag codes, you would bill the ER separately from the IP.

 

[LTibbetts]

ER ADMIT CODES - there is no such thing. Are you talking about ER codes or Initial Hospital Visit codes? If service is provided in the ER to a patient who is then admitted to the hospital by the same physician who provided the ER service, then only the Initial Hospital Visit should be coded - The documentation will determine the level of the code.

Tessa, this is where I get confused. I do the E&M coding for the ER and I have always entered an E&M for every visit, including for patients that are admitted. I have no idea what they charge on the inpatient side. The girls that enter those charges are not coders and only enter what is on the charge slip that the physicians give them to enter, like data entry. We are a CAH and I hope that this is the exception for us as I have been struggling with this. I know from school and from all of the posts on the forums that this is not common practice. I have tried to read through the CAH guidelines and it all is very confusing for me. I am starting to really worry about my well being in this situation. I would hate to think that I had a hand in any wrongdoing and I absolutely do not want be part of any fraudulent activity. Please help, what do you think I should do? Do I need to look further into the CAH guidelines to find the answer?

And thanks for the E&M tools! I got them in the mail yesterday and they will be a very big help so thanks!

 

[LTibbetts]

I have to respectfully disagree with your information FTessabartles. You stated that the er admit would be included with the IP. Please be sure to read your 72 Hour Rule. If it is non-diagnostic, and there is not an exact match between the diag codes, you would bill the ER separately from the IP.

Can you please tell me where to find this information? It might prove to be extremely helpful and I would really appreciate it

I just found this on the web:
Acute care hospitals require the 72-hour rule. Other facilities require the 24-hour rule, such as long-term care hospitals, rehab hospitals, and psychiatric hospitals. Critical access hospitals are excluded from the 72-hour/24-hour provision. As an administrator of a hospital covered under the 72-hour rule, you will need to make sure that hospital billing personnel properly code the patient information in order to ensure that Medicare pays for the correct DRG, and also that all services within 72 hours of the hospital stay are being billed on one claim. Improper coding and billing can cause unnecessary hassles

 

[FTessaBartels]

I have to respectfully disagree with your information FTessabartles. You stated that the er admit would be included with the IP. Please be sure to read your 72 Hour Rule. If it is non-diagnostic, and there is not an exact match between the diag codes, you would bill the ER separately from the IP.

I am only talking about professional fees. CPT and CMS are very clear about this. If the same physician who treats the patient in the ER is the admitting physician then only the Initial Hospital Visit is coded. There is no 72-hour rule that applies to professional fees.

F Tessa Bartels, CPC, CEMC