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Emergency Department Coding & Reimbursement Alert

Educate Physicians to Avoid Downcoding Level 5 Services to 99284 and Losing Reimbursement

- Published on Mon, Nov 01, 1999
In the emergency department, complex illnesses and serious, sometimes life-threatening, injuries are so common that many ED physicians do not appreciate the value of the services they provide and therefore may be losing out financially. Educating doctors for good documentation is key to alleviating the problem.

Although most physicians and coders worry about upcoding and the scrutiny and audits this may trigger, emergency specialists should be more concerned with possibly downcoding their charts, says Jack Turner, MD, FACEP, medical director of documentation and coding compliance for Team Health Inc., a nationwide emergency physician staffing group with affiliates in several states.

ED doctors see serious cases on a regular basis, says Turner. Thus they tend to think of these visits as not as serious. They say, Oh, a hip fracture, or That patient has CHF (congestive heart failure), Ive seen 10 this week. Frequently, Medicare will value what the ED physicians do higher than what the doctor, personally, will think. The physicians undervalue anything they perceive to not be a significant problem.

Many Level 5s Should be Critical Care

Patients in cardiac arrest, multiple-trauma car accident victims, and patients with gunshot wounds are obviously critically ill and require a high level of treatment. However, these patients are often considered by ED physicians to be Level 5 services when, in fact, many of these visits should be reported with critical care codes (99291-99292), Turner says.

One of the biggest problems we as a specialty have is that what an ED physician may think of as a Level 5 is actually critical care, and what they think of as Level 4 is actually a Level 5 service, he says. Many physicians choose E/M codes by myth and by legend instead of by the guidelines Medicare and the other payers follow. (See chart on documentation requirements for reporting 99284 and 99285 on page 83.)

ED physicians do not report critical care services in many of the instances they should, in part due to the stringent documentation requirements and time requirements set forth in CPT, Turner says.

Note: For information on the requirements for reporting critical care, see Improve Utilization of Critical Care Codes to Increase Reimbursement for Emergency Services in the January 1999 issue of ECA, page 1.

Use MDM to Drive Code Choice

A standard rule of thumb in emergency E/M coding is that, in the case of seriously ill patients, those who are admitted are usually Level 5 services and those who end up discharged home are Level 4 or lower, says Susan Callaway-Stradley, CPC, a former ED coder who is now an independent coding consultant in Augusta, SC. If I had to give a general scenario, that is what it would [...]

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