By

Kevin Solinsky, CPC, CPC-I, CEDC, CEMC

Learn components of the ED E&M

Medical Necessity vs MDM

Critical Care coding

Procedure coding

Orthopedic coding

Emergency Room Services◦ 99281 – 99285

Critical Care ◦ 99291 & 99292

Observation◦ 99217-99220, 99224-99246

There are 7 components to define the levels of E/M services:◦ History

◦ Examination

◦ Medical Decision Making

◦ Counseling

◦ Coordination of Care

◦ Nature of Presenting Problem

◦ Time (CC)

History

Exam

Medical Decision Making

Chief Complaint (CC)– required on all charts

History of Present Illness (HPI) (4 of 8 should be on every chart)

Review of Systems (ROS) ( 2-9, 10 OR MORE)

Past Medical, Family and Social History (PMFSH) ( 2 of the 3 should be documented)

The ROS and or PFSH may be recorded by ancillary staff or on a form completed by the pt. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others

HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.

Location Context Quality Timing Severity Duration Modifying Factors Associated Signs and Symptoms

Location◦ RUQ

◦ Left

◦ Upper

◦ Lower

◦ Anterior

◦ Distal

◦ 3rd digit

Context (allows for e codes)◦ Sharpening a knife

◦ Occurred at….

◦ During….

◦ While….

◦ Bit by rat

Duration◦ For 3 hours

◦ Started this morning

◦ For a month

◦ Since yesterday

Timing◦ In the afternoons

◦ Daily

◦ Intermittent

◦ Constant

◦ 20 minutes after..

Quality◦ Sharp

◦ Throbbing

◦ Stabbing

◦ Crushing

◦ burning

Severity◦ Rated a ___out of 10

◦ Severe

◦ Improving

◦ moderate

Modifying Factors◦ Took Motrin

◦ Tried massage

◦ Exacerbated by

◦ Relieved by

◦ Not affected by

Associated Signs and Symptoms◦ No nausea or

vomiting

◦ Also with cough

◦ Also complains of

Brief HPI 1 -3 elements from above

Extended HPI at least 4 elements

Charts that you could bill as 4-5 get down coded if HPI does not have 4 elements

Quality over Quantity◦ Cc: Chest Pain

◦ HPI: This is a 10 year old boy who presented to the ED complaining of throbbing posterior chest pain over the past 5 hours. Pt rates pain a 7 out of 10.

duration Quality Location

Severity

Allergic/Immunologic

Cardiovascular

Constitutional

Ears, Nose, Mouth, Throat

Endocrine

Eye

Gastrointestinal

Genitourinary

Hematologic/Lymph

Integumentary

Musculoskeletal

Neurologic

Psychiatric

Respiratory

99282/99283◦ Problem pertinent ROS = 1 system

99284◦ Extended ROS 2-9 systems

99285◦ Complete ROS at least 10 symptoms

May make statement all other systems reviewed and are negative – means you reviewed all 14 systems!!

A pertinent PFS consists of any 1 element from the PFS

92284 = pertinent

A complete PFS consists of 2 elements from 2 of the PFS areas

99285 Complete need 2

99281 Problem Focused History◦ CC◦ Brief History of Present Illness

99282/99283 Expanded Problem Focused History◦ CC◦ Brief History of Present Illness/Problem Pertinent

ROS

99284 Detailed History◦ CC

◦ Extended History of Present Illness

◦ Extended Review of Systems

◦ Problem pertinent past, family social history.

99285 Comprehensive History◦ CC

◦ Extended History of present illness

◦ Complete review of systems

◦ Complete past, family, social history

99284 or 99285 downcoded to a 99283◦ Only brief HPI documented. A brief HPI limits code to

99283

99285 downcoded to 99284◦ 99285 requires a complete ROS

◦ 99285 requires a complete PFS History

If unable to get a history from pt or source ◦ You must document the reason history is not

obtained and documented in the record

◦ State specifically where the documented history was obtained

◦ Indicate what other sources for history were unavailable

7 body areas◦ Head including face

◦ Neck

◦ Chest including breasts and axilla

◦ Abdomen

◦ Back

◦ Genitalia, groin, buttocks

◦ Each extremity

11 organ systems◦ Eyes

◦ ENT

◦ Cardiovascular

◦ Respiratory

◦ Genitourinary

◦ Musculoskeletal

◦ Skin

◦ Neurologic

◦ Psychiatric

◦ Hematologic/lymphatic

It’s just as important to document negative findings as positives.

99281 Problem Focused◦ 1 body area or system

99284 Detailed◦ 2-7 body areas or

systems 1 in detail

99282/99283◦ Expanded problem

focused 2-7 BODY AREAS

99285 Comprehensive◦ 8 or more Organ

Systems

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:◦ The number of possible diagnosis and/or or the

number of management options that must be considered.

◦ The amount and/or complexity of medical records, diagnostic tests, and/or other info. That must be obtained, reviewed and analyzed.

◦ The risk of significant complications, morbidity and/or mortality, as well as co-morbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and /or the possible management options.

Must meet or exceed 2 out of 3

Straight Forward

Low Complex

Moderate Complexity

High Complexity

# of diagnosis or TX options (total points)

1 = minimal

2 = Limited

3 = Multiple** 4 or more = Extensive**

Amt or complexity or Data (total points)

1 = minimal

2 = Limited

3 = Multiple** 4 or more = Extensive**

Level of risk

Minimal Low Moderate High

Problems to Examining Physician_ Points◦ Self Limited or Minor 1 point

◦ Est problem (to examiner) stable 1 point

◦ Est problem (to examiner) worsening 2 point

◦ **New problem (to examiner)

No additional workup needed 3 points

◦ **New problem (to examiner) 4 points

Additional workup needed/planned

Level of risk

Presenting problem Diagnostic Procedures Ordered

Management options Selected

Minimal 1 self limited or minor problem

Lab tests via venipuncture, xrays, ua, EKG, US

Rest, gargle, bandages dressings

Low 2 or more self limited or minor problems, 1 stable chronic disease, acute uncomplicated illness/injury

Physiological w/o stress, lab via art puncture, superficial biopsy, noncv imaging w/contrast

Minor surgery no risk factors, OTC drugs, IV therapy no additives, PT & OT

Moderate Chronic illness w/exacerbation, 2 stable chronic illnesses, acute illness w/ systemic sxs, complicated acute injury

Physiological w/stress, deep biopsies, obtain fluid from body cavity, endoscopy or cv imaging no risk factors

Minor surgery w/risk factors, RX drug, IV w/additives, closed tx fx or dislocation

High Chronic illness w/ severe exacerbation, illness/injury that pose a threat to life or bodyily fxn, abrupt ∆ in neuro status

Endoscopies or cv imaging w/ risk factors

Elective minor surgery w/risk factors, emergency surgery, RX w/monitoring, DNR decision, Parental controlled substance

History Exam MDM

99281 Problem Focused

Problem Focused

Straightforward

99282 Expanded Problem Focused

Expanded Problem Focused

Low Complexity

99823 Expanded Problem Focused

Expanded Problem Focused

Moderate Complexity

99824 Detailed Detailed Moderate Complexity

99825 Comprehensive Comprehensive High Complexity

99281 Self Limited or minor 99282 Low to moderate severity 99283 Moderate severity 99824 High severity, and require urgent

evaluation by the doc but do not pose an immediate significant threat to life or physiologic function

99285 high severity and pose an immediate significant threat to life or physiologic function.

Medical Necessity

verses

Medical Decision Making

It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.

Discussion

Critical Care: Evaluation and management of the critically ill or critically injured pt, requiring the constant attendance of the physician.

Critical care services include but are not limited to the treatment or prevention of further deterioration of CNS failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postop complications or overwhelming infection.

There is a high probability of sudden, clinically significant, or life threatening deterioration in the pts condition that requires the highest level of physician preparedness to intervene urgently.

Withdrawal of or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the pts condition.

Critical Care services are billed based on the total physician “attendance” time at the bed side,◦ Time entered does need to be at bedside.◦ Time reported does not need to be continuous.◦ The time can be totaled from multiple encounters on

the same day.◦ Must document critical care time of greater than 30

minutes.

Documented Critical Care time should include:◦ Time at bedside with the pt

◦ Conversations with other personnel regarding pt

◦ Clinically necessary conversations with family when pt is unable to participate in decisions

◦ Review of test results

◦ Documentation of encounter

Documented Critical Care time should not include:◦ Time performing separate billable procedures

◦ Time spent by residents managing the pt

◦ Time spent in teaching sessions with the residents

The interpretation of cardiac output measurements

CXRT Pulse ox Blood gases Information data stored in computers Gastric intubation Transcutaneous pacing Ventilator management Vascular access procedures

Endotracheal intubation

Periocardiocentesis

Central Venous Catheter

Chest Tube

CPR 92950◦ The docs progress note must document that time

involved in the performance of separately billable procedures was not counted toward critical care time.

Document procedures step by step and not as a whole

Identify location of injury

Document who performed minor procedures

3 levels◦ Simple, intermediate, complex

Document◦ Number of layers closed

◦ Location of injury

◦ Length of wound

◦ Extra cleaning or debridement beyond normal

Procedure 3.0 cm right cheek laceration was anesthetized with 3.0ml LET Solution and subsequently Lidocaine 1% without Epinephrine 2ml via small gauge needle into the margin. The wound was copiously irrigated and 1 small foreign body was removed. 5-0 Prolene sutures simple interrupted x 4 were placed with excellent apposition of the wound edges. Pt tolerated procedure.

Splinting a fracture that will require reduction or other treatment at a subsequent time is considered “supportive” or temporary

If the fx is definitively treated by splinting or other care provided in the E, the treatment is considered “restorative” or definitive

The exact location of the fracture or dislocation must be noted.

Clear documentation of care provided in the Emergency Department is required.

Reduction, stabilization, devices and materials utilized as well as who provided the care should be noted.

For non-Medicare pts in the ed the doc must either apply the splint/cast or perform a post-placement check of the application in order to bill for the service

Many providers do not understand that Medical Necessity is the driving force for picking the appropriate E&M service.

This diagnosis is a clear example that the patient age, tests ordered and treatment plan are what drive the level of service that should be coded.

99282:no tests or treatment sent home to take Tylenol.

99283:You order blood, and urine no medications, home on Tylenol or Motrin

99284: Blood work, urine, IV fluids, IV or IM medications may go home on antibiotics or not.

99285: Blood work, urine, IV fluids, Spinal Tap, IV antibiotics and administration to the hospital for R/o sepsis.

Chest Pain or abdominal pain always generate a higher level of

medical necessity due to the possibilities with regards to

diagnoses.

This also can drive the level you bill.

We are going to look at charts and review all the components and determine E&M and procedures that can and should be coded.

Disclaimer:

You can put 5 certified coders in a room together and give them the same charts. They can all code them just a little different and still have the same outcome. Coding is not a science we are not perfect and can learn from each other..

Questions

Kevin Solinsky, CPC, CPC-I, CEDC, CEMC

Healthcare Coding Consultants, LLC

ksolinsky@hccconsultants.com

480-200-4590