Coding Strategy

Use these FAQs to achieve level 5.

A patient reports to the emergency department in such severe respiratory distress that she cannot communicate during the history of present illness (HPI) portion of the E/M service. The patient also presents to the ED alone via ambulance, meaning there was no one else to speak for her.

How can a coder decide on the history level for this ED E/M service? Knowing an important exception to the HPI rules in ED settings will help you accurately report these incidents.

When a physician documents that an HPI [history of present illness] is unobtainable due to patient condition, you can invoke the caveat, explains Lori Bettencourt, CPC, PCS, coder at Pro-Medbill LLC in Hampton N.H.

Benefit: The ED caveat can prevent E/M downcoding based on the E/M HPI component. Follow this FAQ to get the lowdown on all the ED caveat rules you’ll need to code correctly each time.

What Are the Caveat Basics?

“In real life, ED physicians are not always able to obtain a complete history from a patient. Of course the physician should always document any history they can obtain from the patient, family or friends, EMS, nursing home, etc.,” says Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass. If the history is limited, however, the caveat “allowsthe physician to receive ’full-credit’ for even a comprehensive history – if you document why the history could not be obtained,” Lemanski stresses.

“The caveat is a CPT exception unique to emergency medicine 99285 services. It provides an exception to the E/M content requirements when the physician is unable to obtain the required [history] information,” relays Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La. This could be due to the urgency of the patient’s condition or the physician’s mental status.

For instance: The ED physician performs a comprehensive exam and high-complexity medical decision making for a patient, but she cannot get enough information from the patient for a comprehensive history. If you invoke the ED caveat in this instance, you might be able to report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity …).

How About a Clinical Example?

Consider this potential ED caveat scenario, courtesy of Edelberg:

A 64-year-old patient presents to the ED with altered mental status and left-sided facial droop. The physician examines the patient, but the patient cannot provide any useful history information. The physician orders a CT scan of the head, the patient is admitted to rule out a stroke. Notes indicate that the physician performed a comprehensive exam and high MDM.

In this scenario, you might be able to invoke the ED caveat if the physician documented her inability to obtain a full history, and report 99285 for the encounter.

How Can I Spot Potential Caveat Claims?

In a perfect world, the physician would stamp “ED caveat” on each relevant claim, but coders will have to be good spotters to make the caveat work for them.

How? Coders might be able to identify caveat situations based on terms the physician uses, says Bettencourt. Some terms that could indicate a caveat if they appear in the notes include:

• history unobtainable
• history obtained by family member due to altered mental status.

Other possible keys: Lemanski offers these terms that might indicate a patient that is unable to fully communicate:

• unresponsive
• obtunded
• comatose
• aphasic
• paralyzed and intubated
• incoherent due to intoxication or drugs.

How Do I Document the Caveat Situation?

In order to submit a successful caveat claim, however, you need to include two specific pieces of information. Find out what they are by subscribing to the ED Coding Alert.

Editor: Chris Boucher, CPC

Want to know expand your medical compliance knowledge? Sign up for the upcoming live audio conference, ED and EMTALA Compliance, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Watch It: If you fly through FAST exam coding, you could miss vital info

When your physician performs a FAST (focused assessment by sonography for trauma) examination, be sure to go through the notes slowly or you could miss one of the three common codes.

FAST exam patients are almost always in some physical trauma, which requires a high-level E/M service; once the physician makes the decision, she’ll perform a pair of procedures to complete the FAST exam.

Use this guide to correct coding so you’ll be quick on the draw when coding for trauma patients requiring FAST exams in your Emergency Department.

FAST Focuses on Trauma Patients

The high acuity of the ED setting is part of the reason that ED physicians perform their fair share of FAST exams; “Common presentations associated with internal bleeding include blunt trauma such as MVAs [motor vehicle accidents] and significant falls,” states Eli Berg, MD, FACEP, CEO of MRSI, an ED coding and billing company in Woburn, Mass.

During a FAST exam, the emergency physician is looking for a collection of fluid in the chest, abdomen, and pelvis, explains Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

According to Jennifer K. Curry, clinical manager for the department of emergency medicine for UMDNJ-Robert Wood Johnson Medical School in New Brunswick, N.J., FAST exam candidates could include patients who have:

• suffered blunt trauma to the trunk/abdomen

• hypotension with abdominal pain

• severe abdominal pain radiating to the back (to rule out aortic dissection)

• abdominal pain with recent cardiac or vascular catheterization with access through the inguinal vascular system (to rule out retro peritoneal bleed).

Remember, Both FAST Codes Require 26

There are two steps to any FAST exam, confirms Curry.

Step 1: The physician performs a limited transthoracic echocardiography (ECG) to check for pericardial fluid, which you should code with 93308 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study), says Berg.

Step 2: The physician performs a limited abdominal ultrasound to check for abdominal fluid, says Todd Thomas, CPC, CCS-P, president of ERcoder Inc. in Edmond, Ok.; report this part of the exam with 76705 (Ultrasound, abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up]).

Consider this example of a possible FAST exam op note from Thomas:

Performed bedside limited US for blunt torso trauma. Pericardial space, right/left upper quadrants and pelvis were visualized: no obvious pericardial effusion or hemoperitoneum, or hypoechoic areas within the liver/splenic parenchyma that were seen. Interpretation: Normal FAST exam.

For this encounter, you’d report 76705 and 93308 for the FAST exam. Remember to append modifier 26 (Professional component) to both codes, reminds Contreras.

Why? Modifier 26 shows the insurer that you are not billing for the equipment, only your physician’s services.

© ED Coding Alert.

Learn how to spot the FAST exam cases that fall short of the requirements for a level-5 E/M: Download your 2 FREE sample issues here.

AUDIO Training Event: The ED Coder’s Guide to 2010 coding & reimbursement. With Caral Edelberg, CPC, CCS-P, CHC.

Related articles:

1. Coding for OB Ultrasounds and Annual ExamsCoding for OB Ultrasounds Are you confused about ultrasound coding?...
2. Radiology Coding Education: Is 76705 OK for Back?Question: For a lower back ultrasound of a soft tissue...
3. Pediatric PE Coding: Look Out for These Documentation Misses Here’s why oral thrush could be a major issue....

Question: A 42-year-old patient reports to the ED early on Tuesday morning for evaluation of uncontrollable shaking in her extremities and severe pain in her neck. The EP admits the patient to observation at 7 a.m. and orders blood tests and a CT scan — however, the shaking continues to worsen. The EP consults with a neurologist, who recommends hospitalization. The neurologist then admits the patient to the hospital as an inpatient at 6:25 p.m. Tuesday for more examination. Notes indicate a comprehensive history and exam, along with moderate medical decision making. Should I code this as an observation, or some other E/M service?

Answer: The ED physician could use an initial observation code in this situation.

On the claim, report 99235 (Observation or initial hospital care, …) for the E/M with 781.0 (Abnormal involuntary movements) and 723.1 (Cervicalgia) appended to represent the patient’s symptoms. ED physicians do not admit patients to hospital inpatient status (though they can recommend hospitalization); the neurologist will code for those services.

© ED Coding Alert. Download your 2 free sample issues here.

AUDIO TRAINING EVENT: Caral Edelberg, CPC, CCS-P, CHC tells ED coders all they need to know — and only what they need to know — for 2010. STAT.

Related articles:

1. Capture ‘Patient Limbo’ Period With These Observation Coding Steps Internist deciding on admission? That’s your signal to look...
2. 5 Steps Ensure Correct Observation Care Coding To prevent ED denials, code service only when doc...
3. Observation Coding Do’s and Don’ts What’s the POS for an ED hallway? Answers to...

No maybes here: Answer this question wrong and you will code incorrectly.

When your ED physician performs fracture care for a patient, be ready to pounce on evidence of manipulation, as CPT often breaks fracture care codes along the manipulation line.

The $kinny: Let’s say the physician performs closed treatment on a fractured collarbone; if she uses manipulation, the service is worth about $106 more than a nonmanipulation encounter.

Use this FAQ to successfully manipulate both types of fracture care codes — and ethically add to the practice’s bottom line.

What Is Manipulation?

For coding purposes, “manipulation involves reduction or attempted reduction of the fracture or dislocation,” explains Gerri Walk, RHIA, CCS-P, senior manager for Baltimore’s Health Record Services Corporation.

There is “open” manipulation, but your ED physicians will almost always perform “closed” manipulation, which occurs when “the physician is repositioning or relocating a displaced closed fracture back to the correct anatomical position without surgically opening it,” says Nicole Benjamin, CPC, CEDC, coding education specialist for the American Academy of Professional Coders (AAPC).

When the ED physician provides manipulation, make sure he remembers to document it, “since an orthopedic doctor can be called to treat these fractures as well,” Benjamin recommends. If you don’t ID manipulation, you could end up costing your ED deserved cash on certain fracture fixes.

Payout: Let’s look at CPT codes for closed treatment of a fractured collarbone: 23500 (Closed treatment of clavicular fracture; without manipulation) and 23505 (… with manipulation). Code 23500 pays about $184 (5.09 transitioned facility relative value units [RVUs] multiplied by the 2009 Medicare conversion rate of 36.0666); while 23505, with 8.05 RVUs, pays about $290.

How Can I Identify Manipulation?

Unfortunately, the word “manipulation” does not make its way into physician encounter notes very often, reports Denise Katz, coder for Dr. David Silverberg in Las Vegas. “Generally, the term ‘closed reduction’ is used for non-operative treatment of fractures that are treated without surgery,” she explains.

Look for: Other key terms that might lead you to a decision on manipulation include “reduce,” “align,” and “reset,” Katz says.

What Do Open, Closed Tx Scenarios Look Like?

Consider this pair of examples; one contains evidence of manipulation, while the other does not:

Example 1: A 22-year-old male patient reports to the ED with an injured right index finger; the injury happened when an opponent in a football game tackled him. The ED physician documents a level-three E/M, which includes a finger X-ray and administration of pain medication. After reviewing the X-ray the ED physician diagnoses a displaced fracture of the distal phalange. The physician notes that he “reduced finger at distal end, reset fingertip.”

He then places the finger in a splint and refers patient to an orthopedist for follow-up care.

This is an example of manipulative care. On the claim, Benjamin recommends that you report the following:

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity …) for the E/M

• modifier 57 (Decision for surgery) appended to show that the E/M led to the fracture treatment

• 26755 (Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each)

• modifier 54 (Surgical care only) appended to 26755 to show that you are not providing any follow-up care

• 816.02 (Fracture of one or more phalanges of hand; closed; distal phalanx or phalanges) appended to 99283 and 26755 to represent the fracture

• E886.0 (Fall on same level from collision, pushing, or shoving, by or with other person; in sports) appended to 99283 and 26755 to represent the cause of the injury. (Note: Beginning Oct. 1, use E007.0 [Activities involving American tackle football] instead of E886.0.)

Example 2: A 16-year-old male patient reports to the ED with an injured left index finger, which happened during a tackle football game. The ED physician documents a level-two E/M with an X-ray and pain meds. After reviewing the X-ray the ED physician diagnoses a proximal phalanx fracture on the hand, which he splints. The encounter notes read “non-displaced fracture splinted in good position. Treatment with NSAIDS for pain.” He refers the patient to an orthopedist for follow-up care in 10-14 days.

This is an example of non-manipulative care. On the claim, report the following:

• 99282-57 (… an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity …) for the E/M

• 26750-54 (… without manipulation, each) for the fracture care

• 816.01 (… middle or proximal phalanx or phalanges) appended to 99282 and 26750 to represent the fracture

• E886.0 appended to 99282 and 26750 to represent the cause of the injury. (Or E007.0 after Oct. 1.)

© ED Coding Alert. Download your 2 FREE sample issues here.

AUDIO: Are you missing other things in your doctors’ notes? You’re not alone. Top ED Procedures Most Coders Miss. With Caral Edelberg.

Related articles:

1. How Do I Code This Multiple Fracture Accident Patient?Question: A 30-year-old female presents to a rural ED with...
2. Sort Out This ER, Then Assumed Care ScenarioQuestion: My orthopedist treated a patient who was first seen...
3. Weber B Fracture Repair: 27786, 27788 or 27792?Question: Which CPT and ICD-9 codes should we report when...