Use these frequently asked questions (FAQs) to reach level 5.
A patient informs the emergency department (ED) with such severe respiratory distress that he is unable to communicate during the current illness history (HPI) portion of the Assessment/Management service. The patient also presents to the ED by ambulance alone, meaning there was no one else to speak for her.
How can a medical coder decide the level of history for this emergency department E/M service? Knowing one important exception to HPI rules in emergency department settings will help you report these incidents correctly.
When a doctor documents that an HPI cannot be obtained due to the patient’s condition, they can invoke the warning, says Lori Bettencourt, CPC, PCS, coder for Pro-Medbill LLC in Hampton NH.
Advantage: ED warning may postpone E/M downcoding depending on the E/M HPI component. Follow this FAQ for all the ED warning rules you’ll need to code correctly every time.
What are the warning basics??
“In real life, emergency department Doctors are not always able to obtain a complete and comprehensive history from a patient. Of course, the doctor should always document any history they can get from the patient, family or friends, EMS, nursing home, and the like,” says Michael Lemanski, MD, director of ED billing at Baystate Medical Center in Springfield, Massachusetts. If The history is limited, but the caveat “allows the doctor to get full credit” even for a complete history, if he documents why the history could not be obtained, Lemanski emphasizes.
“The warning is a CPT waiver unique to 99285 Emergency Medicine Services. Provides an exception to the Assessment/Management content requirements when the physician is unable to obtain the required requirements.” [history] information,” says Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, Louisiana. This could be due to the urgency of the patient’s condition or the physician’s state of mind.
For example, him emergency department The doctor performs a comprehensive examination and highly complex medical decision-making for a patient, but is unable to obtain adequate information from the patient for a complete history. If you invoke the emergency department warning in this case, you could opt for 99285 (Emergency department visit for a patient’s E/M, which requires these three vital components within the limitations imposed by the urgency of the patient’s clinical condition. ). condition and/or mental state: complete anamnesis, complete examination, highly complex medical decision-making…).
How about a clinical instance??
Consider this likely ED warning scenario, courtesy of Edelberg:
A 64-year-old patient presents to the emergency department with altered mental status and drooping on the left side of his face. The doctor examines the patient, however the patient is unable to provide any useful history information. The doctor orders a CT scan of the head, the patient is admitted to rule out a stroke. The notes point to the fact that the doctor conducted a full examination and high MDM.
In this situation, you may be able to call the emergency department warning if the doctor documented your inability to obtain a complete history and report 99285 for the encounter.
How can I identify potential warning claims??
In an ideal world, the doctor would stamp “ED warning” on every relevant claim, however coders will have to be keen observers to make the warning work for them.
How? Coders could spot warning situations based on the terms doctors use, Bettencourt says. Some terms that could signal a warning if they appear on the cover notes:
– unreachable history
– Antecedents obtained by a family member for altered mental status.
Other Possible Clues: Lemanski offers these terms that could point to a patient who is not able to fully communicate:
- insensitive
- obtained
- comatose
- aphasic
- paralyzed and intubated
- inconsistent due to intoxication or drugs.
How should I document the warning situation??
However, to file a successful warning claim, you must include two specific pieces of information. Find out what they are by registering on the ED Coding Alert.
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