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Make certain that documentation supports the right level of service.

I have been doing a project assessing emergency providers’ documentation and their evaluation and management (E&M) levels of service (LOS), and want to share some information with you.

Anyone who deals with professional fees anywhere other than in the office is familiar with trying to get providers to comply with the CPT (Current Procedural Terminology®) component requirements. Those components are history (which comprises history of present illness, past medical, social, and family history, and review of systems), physical examination, and complexity of medical decision making (MDM). Office billing is no longer component-based, since January 2021.

I understand how a medical professional can undervalue their services and down-code unintentionally. What I don’t understand is how, if a provider is selecting an appropriate level of service, they fail to fulfill the requirements to bill at that level. CPT provides us with a rubric, for Pete’s sake!

When I was in grade school, they assigned an essay, gave you a topic, and turned you loose. Kids today are given a rubric: a precise recipe detailing exactly what is needed to achieve the various grades. If you don’t do an introductory paragraph with three sentences, your grade is predictably adjusted downward. You know what your teacher’s expectations are.

In the emergency department, there are five levels of service in the 9928- series:

  • 99281 requires a problem-focused history and a problem-focused examination, with straightforward MDM. These patients have very minor or self-limited problems.
  • 99282 demands an expanded problem-focused history and physical exam (PE) with MDM of low complexity. The presenting problem is of low to moderate severity.
  • 99283 has the same history and PE requisites as 99282, but the MDM is of moderate complexity. The presenting problem is of moderate severity.
  • 99284, likewise, has MDM of moderate complexity, but what distinguishes it from Level 3 is that the history and physical need to be detailed. The presenting problem is of high severity and requires urgent evaluation, but does not pose a threat to life or limb.
  • 99285 has the highest bar. Comprehensive history and physical examination, high complexity of MDM, and the presenting problem is of high severity, posing an immediate threat to life or limb.

The difference between levels 2 and 3 is the complexity of MDM. The difference between levels 3 and 4 is the extent of the history and physical examination. I tell providers to figure out where on the spectrum the presenting problem lands and then flesh out the history and physical examination to satisfy the requirements for the appropriate LOS.

There are guidelines as to what constitutes problem-focused versus expanded problem-focused versus detailed versus comprehensive histories and physical examinations. I can’t understand not including at least four elements for the HPI – what is the issue, how bad is it, when did it start, is it constant or fluctuating, does anything make it worse or better, are there any associated symptoms? These are questions that can and should be asked and documented for any condition. Everyone should have some elements of PFSH – medications and allergies, past medical history, and whether a patient smokes, drinks, or does drugs – those elements are always clinically relevant.

Often, the determining factor ends up being the review of systems (ROS). With a compliant caveat, it can always be rendered complete. And any patient can have a constitutional assessment and examination of eyes, mucous membranes, lungs, heart, abdomen, and neurological and psychiatric systems to fulfill a comprehensive physical examination. Therefore, any patient can have a Level 5 history and physical examination documented. The rubber meets the road at MDM. What is the nature of the presenting problem? Is there medical necessity to perform a comprehensive history and physical?

I instruct my providers and coders to assess the presenting problem and determine which bucket the patient belongs in, according to medical necessity: critically ill (or injured, for all categories; cross 30 minutes – critical care time, otherwise 99285), really sick (99285), sick (99284), somewhat sick (99283), not particularly sick (99282), or not sick and shouldn’t even be in the ED (99281). Then, I tell them to make sure their documentation supports whatever level they picked.

In the ED, for initial hospital or observation care, and for other new patient care in non-office venues, the threshold must be met for all three components. Established patients, such as those receiving subsequent hospital, observation, or nursing facility care, must meet two out of the three components. I recommend that MDM is always one of the components.

MDM merits its own discussion. We will pick up there next week.

Programming Note: Listen live to Dr. Erica Remer as she cohosts Talk Ten Tuesdays with Chuck Buck, Tuesdays at 10 Eastern.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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