The American Academy of Professional Coders (AAPC) has published an article written by Access Healthcare' Gayathri Natarajan, CPC, COC, Director of Coding in the June-2018 edition of its Healthcare Business Monthly Magazine. The article titled, “Two Best Practices to Improve Emergency Coding*” is the first part of a two-part series and focuses on:
Educated coders and providers are crucial to claim success
Educating ED clinicians on clinically significant and relevant documentation is key to achieving compliant coding and optimizing reimbursement. This is especially challenging in the ED because the provider documentation must support the ED provider’s professional services, as well as billing and coding for the facility. The professional ED level — like other professional evaluation and management (E/M) services — is based on the level of history, examination, and medical decision-making (MDM) documented in the medical record. Whereas the facility ED level is driven by the extent of services rendered by nursing and ancillary staff. Providers must be aware of the documentation requirements to support their professional services — specifically, the requirements of the patient history, exam, and MDM
History
Within the history component, the history of presenting illness is typically the weakest element of the documentation. Most practice management systems have built-in electronic health record (EHR) templates that can be customized to capture elements of the patient’s chief compliant (CC).
The elements within the HPI are:
Location – Where on the body is the sign or symptom located?
Quality – Describe the sign or symptom.
Severity – Describe the intensity of a sign or symptom.
Duration – How long has the sign or symptom been present?
Timing – When does the sign or symptom occur?
Context – What proceeds or accompanies the sign or symptom?
Modifying factors – What reduces or increases the sign or symptom?
Associated signs and symptoms – Describe co-existing problems that accompany the signs or symptom.
Exam
Documentation cloning in the exam component can be a problem when using an EHR. For example, the provider may use the same comprehensive documentation of physical exam for every patient/ visit, even if such an exam is not pertinent to CCs. This calls into question the legitimacy and medical necessity of the service. ED providers should ensure the documentation is pertinent to the visit. Although the templates and shortcut features in an EHR may save documentation time, it’s very important for providers to doublecheck the clinical information submitted to be certain it’s relevant and unique to the patient’s current visit. Some EHRs have an audit trail feature to track historical information such as how often the documentation was cloned by pulling in previous entries. The Centers for Medicare & Medicaid Services (CMS) insist on personalized documentation of each encounter, and recovery audit contractors (RACs) continue to identify and focus audits on cloned documentation. Providers should also watch for auto-populate functions in EHRs, which can lead to documentation errors. Providers should avoid notes that state “seen and agree,” “all systems are reviewed and are negative,” “14-point review unless indicated otherwise,” etc. To avoid cloning, the EHR should be built with a system intelligence to prompt queries when templated documentation is used.
MDM
Additional work the provider does, including tests ordered and management options chosen, must be documented clearly because that information drives the level of MDM. On the facility side, special emphasis is required for documentation of start and stop times, mode/route of administration, etc., when handling hydration, injections, and infusions. When rendering critical care services, providers most often miss documenting the face-to-face time spent on critical care (and the opportunity to report critical care codes). Providers most often pull the problem list and management from the previous patient encounter, which can result in over documentation and up-coding. Templated statements, such as “Labs and radiological investigations ordered and reviewed,” are inadequate to determine the appropriate level of workup done.
Documentation should specify the type of workup, along with findings. Below are examples of acceptable documentation:
Chest X-ray done on 03/28/2018 revealed mild atelectasis with no radiographic evidence of acute cardiopulmonary process.
Labs done on 03/28/2018, revealed the following: glucose 135, elevated; sodium 139 mmol/l; potassium 3 mmol/l, low; chloride 90 mmol/l; total co2 content was 30 mmol/l; bun was 9 mg/dl; creatinine 0.60 mg/dl. osmolarity calculated was 285. calcium level 9.7 mg/dl. total protein was 6.9 gram/dl. albumin level was 3.7 gram/dl, low. WBC 5.9, RBC 4.31, hemoglobin 11.1, hematocrit 35.9, and platelet count was 139, low.
Educate Coders on how to select ED service levels
Because ED coding encompasses both professional and facility services/billing, you must know how to scour documentation to determine the correct ED service level for both settings. Because the professional and ED levels are determined by different criteria, they will not necessarily match for the same patient/encounter.
Quick Tips for Physician Coding
On the physician side, there are several key points to help determine an ED service level. The National Government Services update, effective July 1, 2017, clearly distinguishes an expanded problem-focused exam, versus a detailed exam. This eradicates the need for individual interpretation of an ambiguous coding guideline and helps to select the appropriate ED level.
The nature of a patient’s presenting problem is key to determine the appropriate level of risk under MDM. Choosing between 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 and 99284 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity is especially difficult because both levels support moderate complexity MDM. Elements on the risk table help to distinguish a “low moderate” versus “high moderate” level of risk.
Clinical Documentation Improvement (CDI)
ED coders should focus on identifying and cataloging documentation improvement opportunities for each physician to improve coding specificity and missed documentation of specific procedures that could have been captured. Coders and CDI experts can help institutionalize comprehensive documentation practices through repetitive reviews and provider education. Well-designed electronic ED charting tools and scribe utilization can help reduce revenue leakage due to missed procedures by making sure the documentation is completely reviewed and attested to by the physician. Some of the most effective ways to improve clinical documentation completeness and accuracy are:
With the aid of applications, such as computer assisted coding and natural language processing, the documentation is scanned for key terms and unstructured notes that are reviewed by CDI professionals for areas of improvement.
Strengths, weakness, opportunities, and threats (SWOT) analysis and trend reports generated by physicians, detailing the top three to five areas of documentation improvement to focus provider education, preferably using relevant examples to a small group of providers.
Provider “report cards” to track progress of revenue trends, and follow up audits on documentation post education.
Key Areas to Help You Select Facility ED levels
There is no national standard that drives the facility ED level. CMS requires each hospital to establish its own billing guidelines, as restated by the Outpatient Prospective Payment System (OPPS). Most facilities follow a customized grid/point system. Points are assigned based on sufficient documentation for each of the grid parameters summing up to the final ED facility level to aid appropriate payment by Ambulatory Payment Classifications (APCs), which is the payment methodology under the OPPS.
Common types of services credited to the facility side include:
Mode of patient arrival
Triage
Vital signs
Nurse notes
Nursing assessments
Other assessments (airway, breathing, and circulation (ABC), visual acuity, pain, etc.)
Psychological social status • Isolation services • Social worker notes • Teaching time
Care rendered towards ostomy, wound care, etc.
Specimen collection (urine samples, throat swab, wound swab, etc.)
Translator and interpret services
Type of discharge disposition
About Gayathri
Gayathri Natarajan is a certified professional coder with over a decade of experience in leading large-scale medical coding teams across a diverse range of specialties. As the director of coding services, she provides leadership to education & training programs, compliance, medical coding process automation, and process transition activities at Access Healthcare.
About AAPC
AAPC is the world’s largest training and credentialing organization for the business of healthcare, with more than 175,000 members worldwide who work in medical coding, medical billing, clinical documentation improvement, medical auditing, healthcare compliance, revenue cycle management, and practice management.
About Healthcare Business Monthly
Healthcare Business Monthly, written by and for AAPC's 175,000 members, is the largest and most respected journal for the healthcare reimbursement process.
*originally featured in AAPC's Healthcare Business Monthly