American College of Emergency Physicians

Coding and Reimbursement Pearls

The below documentation, reimbursement and coding topics are designed to be short articles that are suitable for publication in your groups newsletter or email notifications.

Behavior Modification Counseling
Critical Care
Critical Care - Part Deux
EFAST Exam
Electronic Medical Record (EMR)/Electronic Health Records (EHR)
Emergency Department After-Hours Code
Fast Exam
HAC and POA
Hospital Observation Services-Technical Component
In-House Emergencies
Laceration Repair
Level 5 Caveat
Level of Service
Medicare Resources
Medicare's Teaching Physician Guidelines
Moderate (Conscious) Sedation
Observation Services
Physical Exam (PE) Requirements

Behavior Modification Counseling (Top)
Behavior Modification codes are available for tobacco use (CPT^® 99406-99407) counseling; alcohol and/or substance abuse structured screening and brief intervention (CPT^® 99408-99409, Medicare G0396-G0397). These services are time-based and may be separately identifiable services in addition to Evaluation/Management services. Document face-to-face time spent counseling. Retain standard screening tool (e.g. AUDIT, DAST, T-ACE, SBI) in the medical record.

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only. The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date. The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer. For information about this FAQ/ Pearl, or to provide feedback, please contact Jessica Adams, ACEP Reimbursement Director, at jadams@acep.org.

Critical Care (Top)
Do you know how to use Critical Care codes (99291-99292)? Critical Care is defined as an illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition and that the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition. This underused code set requires physician documentation of the time spent directly managing the unstable or potentially unstable patient. Time spent documenting, reviewing labs and radiographs, and speaking with medical staff also counts towards total critical care time. Time spent on separately billable procedures, like CPR (92950), doesn't. You must have provided at least 30 minutes of services to bill, and the "first hour" of critical care includes the first 74, not 60, minutes. Additional time increments over the initial 74 minutes are billed with 99292 for each additional 15-30 minute segment. Time must be clearly documented by the provider and does not need to be continuous.

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Critical Care - Part Deux (Top)
While there are codes you may use in addition to critical care (99291 and 99292), CPT bundles certain separately identifiable services into the codes for critical care. The bundled codes are included in the list below:

the interpretation of cardiac output measurements (CPT 93561, 93562)
chest x-rays (CPT 71045, 71046)
pulse oximetry (CPT 94760, 94761, 94762)
blood gases, and information data stored in computers
gastric intubation (CPT 43752, 91105)
temporary transcutaneous pacing (CPT 92953)
ventilatory management (CPT 94656, 94657, 94660, 94662)
vascular access procedures (CPT 36000, 36410, 36415, 36540, 36600), these are peripheral access. Central access is not bundled.

Any procedures not on this list can be billed separately, and the time spent performing additionally billed procedures must be deducted from Critical Care time and indicated in the record. A statement such as "Critical care time spent in direct management of this patient was 75 minutes exclusive of separately billed procedures" it is recommended.

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EFAST Exam (Top)
Did you know that billing for an EFAST exam may involve three different CPT codes (76705, 93308, & 76604)? The EFAST exam involves limited ultrasound examination of the abdomen (76705), heart (93308), and lungs/chest (76604). In order to bill for an EFAST, each of the three component ultrasounds must be documented. Likewise, as with all emergency department ultrasound codes, documentation must include medical necessity for each study, interpretation, and image retention. Of note, physicians may bill for serial EFAST exams so long as the repeat ultrasounds are medically necessary (e.g. patient deterioration). To bill for repeat exams, use the -76 modifier denoting “Repeat procedure or service by the same clinician.”

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Electronic Medical Record (EMR)/Electronic Health Records (EHR) (Top)

The Electronic Medical Record (EMR) or Electronic Health Record (EHR) is here to stay. There are many different vendors. For emergency medicine, the big difference is whether your department opts for an enterprise system or a boutique system that is specifically designed for emergency medicine. The decision as to which type of EMR you should choose is typically made in conjunction with your hospital system. The challenge after choice is preparation and implementation to minimize care disruptions.

Key considerations to address during the preparation phase:

Understand and map typical pre EMR workflows for all members of the department team. This goes beyond clinical providers. Each provider group should have input in the development of their new workflow.
Managing and testing the reports/access to the EMR that your coding staff/billing company have is key to assuring that the coding transition goes smoothly. Do not assume if moving from paper to EMR that the coders easily have all information. These interfaces need to be built.
Most EMR companies have generic training modules, encourage the development of local "super users" or "Champions" who can alter and/or teach the EMR based on your department workflows.
Identify an on-site EMR specialist to serve as the liaison for the providers/users and the EMR vendor
Obtain comprehensive, quality training to support providers throughout the implementation process and beyond - in all but the smallest of institutions on-going system customization and training new staff as old ones turnover is a full time need
Make sure existing hospital/department electronic systems have supportable interfaces with the EMR
Require a comprehensive education and orientation to all providers including all end users prior to implementation
Visit departments who have recently implemented the EHR to discuss what worked and what didn't

Key considerations to address during the implementation phase:

Extra staffing during implementation phase as throughput will be affected by the learning curve
Make sure there is 24 hour support and troubleshooting team in the first month
Assure that ED specifically trained support continues to be supported for updates and future changes

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Emergency Department After-Hours Code (Top)

Tired of working night shifts? There is a code is available to report services provided in the ED after10 pm. Patients presenting to the ED between10 pm and 8 am may have code 99053 (After-Hours code) reported in addition to the standard 99281-99285 for emergency department levels of service. This code is not typically paid by governmental payers, but can result in modest additional payments from others.

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FAST Exam (Top)

Focused Assessment with Sonography for Trauma (FAST) exam is an increasingly valuable tool for many EPs, but the documentation and coding requirements are often misunderstood. There is no single CPT code that captures the components of a typical FAST exam. Most FAST exams consist of two distinct US exams, limited cardiac (93308) and limited transabdominal (76705). Documentation should clearly reflect two separate and distinct exams. Some providers may also perform a limited chest US (76604) to evaluate for hemo/pneumothorax. Performance of the respective components of the FAST exam will of course depend upon the circumstances of the patient's clinical presentation/progression. Code for the components that were performed and documented.

Note that ultrasound CPT codes are “global” service codes, and combine the technical and professional component of the examination. The professional component is indicated by the -26 modifier, and includes interpretation of the ultrasound study with preparation of a separate signed written report.

A typical report for an US exam performed in the ED typically includes the following elements (and should be a part of the medical record):

Date and time of study
Name of patient
Hospital ID (medical record) number of patient
Indication for study (i.e. Blunt trauma, penetrating trauma, hypotension, abdominal pain)
Name of the person(s) who performed the study
Study finding(s), describing the organ/area studied
Limitations and recommendations for additional studies
Study impression
Name of the person who interpreted the study
Date and time the report was signed

Image archiving refers to the storage and retrieval of an ultrasound image. For billed studies, it is essential that ultrasound images be stored and archived for future review. Simply documenting FAST as "normal" or "negative" does not meet documentation requirements. For additional information, please reference the ACEP Ultrasound FAQs.

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HAC and POA (Top)

Hospital Acquired Conditions (HAC) and Present On Admission (POA) are a pair of terms influencing hospital reimbursement for inpatients. Conditions occurring during an emergency department visit are considered POA Payers may reduce or eliminate inpatient reimbursement for a variety of hospital-acquired conditions that are not present on admission. Coders and reimbursement staff are querying physicians about conditions not clearly documented as present in the ED prior to admission.

ED physician documentation is crucial to support whether or not a condition was present at the point of hospital admission. Some key ED documentation opportunities include:

Infections or complications of urinary catheters, dialysis ports and PICC lines;
Infections of integumentary, genitourinary, respiratory systems;
Sepsis;
Staged decubitus ulcers;
Context of injuries (e.g. falls);
Adverse drug effects and reactions;
Interpretation of abnormal lab values (e.g. blood glucose, PTT and electrolytes).

While the terms “rule out”, “suspected” and “probable” relating to conditions cannot be coded as established diagnoses for ED physician billing, recording of these differential diagnoses are valuable for the inpatient-coded record, which must capture these for inpatient diagnosis billing purposes. Your HPI, ROS, PMH and Clinical Impression documentation are more important than ever to support reimbursement for your hospital partner.

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Hospital Observation Services – Technical Component (Top)

Emergency Medicine Revenue Source: Observation. Remember, Observation, or Extended Assessment and Management (EAM) as it is called for technical billing, is not a place, it is a status! If admission is a foregone conclusion, write for a full Admission, not Observation. The decision process is whether to Admit to inpatient status, place the patient in Outpatient Observation, or Discharge the patient home. Physician services for observation in the ED are billed in place of the ED visit code (99281-99285 or 99291), not in addition to them. When the hospital bills for the technical (hospital) portion of Observation generated from the ED, the hospital must bill an ED visit 99284, 99285 or Critical Care 99291 in order to have Observation recognized for payment. This is a major difference from the physician coding and billing policy which recognizes either Observation (99218-99220 or 99234-99236) or the ED Evaluation and Management Codes (99281-99285 or 99291).

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In-House Emergencies (Top)
When you are called to the floor for a code or other emergency, remember to document each of your procedures and services. You may be able to bill for an initial consult if your expertise is required beyond that of the attending service, and the attending or other designee has requested your expertise. Be sure to document the name of the person who requested your consultation. A written order for your consult is appropriate. It is important to know whether the patient status is Inpatient or Observation. Alternatively, greater than 30 minutes of time may support Critical Care, when total time is exclusive of separately billable procedures. Otherwise, you may be able to charge for Inpatient hospital care. Include in your note participation in CPR, ETT, Arterial/Central Venous/ Intraosseous Line insertions, Paracentesis, Thoracostomy, etc. Peripheral IV insertion requiring physician skill may be captured with documented medical necessity (e.g. multiple unsuccessful attempts by nursing staff).

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Laceration Repair (Top)
1. These valuable procedures are categorized by CPT^® as Simple, Intermediate, or Complex. Remember that not all single layer repairs are automatically considered simple. If the wound is heavily contaminated and requires "extensive cleaning or removal of particulate matter" a single layer repair may be reported as Intermediate. Note the size, suture, staple and/or adhesive material used for each layer, and specific anatomical location for each laceration repair. This information guides the coders to identify the repair as simple, intermediate or complex.

2. Capture charges for re-checks and suture removal following simple laceration repair for patients covered by Medicare, and payers which follow Medicare payment policies. There is no global period for simple wound repairs (CPT^® 12001-12018). Intermediate and complex laceration repairs have a 10-day global period for Medicare.

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Level 5 Caveat (Top)

The definition of 99285 includes the concept that the History, Physical Exam, and Medical Decision Making (key requirements) must be met "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status". This concept is called the emergency medicine caveat or the acuity caveat. Although the Medical Decision Making is referenced as one of the elements, the general consensus is that the caveat would apply to the History and Physical Examination. Most Medicare carriers require a description of the patient's urgent condition that prevents obtaining any of these key elements of the Evaluation and Management service as well as the physician's thought process through the discussion of risk factors, differential diagnoses, procedures, diagnostic studies, interventions and disposition. So make sure to document why the severity of your patient's illness and/or procedures such as intubation on arrival preclude or prevent performing a full History or Exam.

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Level of Service (Top)

Remember, you do not get reimbursed for what you do, you get paid for what you document about what you do! A frequent deficiency area for down coding a 99285 to a 99284 is the Review Of Systems (ROS). 99284 requires that you record a review of 2 - 9 systems with while 99285 requires the recording of ten or more. Listing of pertinent positives and/or negatives with the statement 'all other systems reviewed and negative' meets 99285 requirements. Also, remember to record your History of Present Illness (HPI) and Past, Family, and Social History (PFSH) as failure to document both appropriately can result in significant down-coding of your medically necessary services. For the HPI, 99284 and 99285 require documentation of four HPI elements. For the PFSH, 99284 requires recording of one of three PFSH elements and 99285 requires recording of two of three PFSH elements.

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Medicare Resources (Top)

In the past several years, the Centers for Medicare and Medicaid Services (CMS) has published updates to coverage decisions through their MedLearn format. This information provides a reference for many topics relevant to emergency medicine.

With implementation of the new Medicare Administrative Contractors (MACs), many changes to the way you interact with Medicare will be taking place. The Medicare website is a valuable source of news and information regarding Medicare processes and changes in your specific practice location. Log on to their website for additional information. Click on the links below to find specific information regarding your contractor and any changes taking place.

Medicare Learning Network (MLN) Publications & Multimedia links: http://www.cms.hhs.gov/MLNProducts/

Medicare Review Contractor Directory - Interactive Map: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/

*It is recommended that you ensure your system is protected when opening any zip files.

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Medicare's Teaching Physician Guidelines (Top)
Emergency Physicians, engaged in teaching interns, residents, fellows (IRF) and medical students as part of the attending's clinical practice, must satisfy unique requirements in order to qualify for reimbursement by Medicare. Specific rules govern the documentation of the history and physical exam, as well as any procedures that are performed.

Does this matter to me?

If you are a physician who sees patients with a medical student, intern, resident or fellow and you want to be paid, it does.

For Evaluation & Management (E/M) services, the teaching physician (TP) must be involved in the care of the patient by:

personally performing the entire service independently from an IRF; or
having the IRF render the service and discussing it with them, but also independently performing, at minimum, the "key portions" of the service; or
having the IRF render the service and discussing it with them, and also being directly present (i.e. in the same exam cubicle), at minimum, when the "key portions" of the service are performed by the IRF.

What can medical students do?

Medical students are limited to gathering certain aspects of History: Past, Family, Social History, and Review of Systems.

What must I document for a TP E/M?

At a minimum, you must personally document that you were physically present for or performed the "key portion" of the service and that you participated in the management of the patient.(Be sure to check the ACEP website for documentation examples minimally acceptable to Medicare.)
Your documentation must include a legible signature or an electronic signature that is password protected, and it must also include the date.
It is acceptable for a teaching physician to use an electronic medical record (EMR) macro (defined text phrase) to report his/her required personal documentation and should document any variances or corrections of the resident note.

What is the "key portion" of patient treatment?

This is defined by you, the teaching physician, but is susceptible to retrospective appraisal on audit. Determination of "key portion" should be based on the clinical aspects of the case (e.g. presentation, diagnosis, level of service, etc.) and the competency of the particular IRF.

What about time-based services such as Critical Care?

For the reporting of time-based services, such as critical care or moderate sedation, the teaching physician must be directly present during the entire reported time period. Additional teaching time performed during a critical care encounter cannot be added to the total critical care time. Both the TP and IRF cannot bill for simultaneous Critical Care time.

What about procedures?

For procedures taking longer than 5 minutes the Teaching Physician must be directly present for at least the "key portions".
If the procedure will take less than 5 minutes to perform, the Teaching Physician must be directly present for the entire procedure.

For additional information on Teaching Physicians, see the Teaching Physicians Frequently Asked Questions and the CMS policy transmittal on the ACEP website. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

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Moderate (Conscious) Sedation (Top)
Don't overlook sedation services provided by the ED physician solely or in support of another provider such as an orthopedist. Fill out your hospital conscious sedation forms and submit these to your coders to document the necessary information to bill for these services. Moderate Sedation codes include an initial code for the first 30 minutes of intra-service time, continuous time from meds given until your personal contact ends, (this code is fulfilled after 16 minutes is documented) and a code for every 15 minutes of intra-service time thereafter (fulfilled after 8 minutes). When calculating the total sedation time, be sure to only include the minutes involved in direct face-to-face monitoring of the patient, exclusive of separately identifiable evaluation and management prior to sedation and the time following the procedure performed (patient recovery).

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Observation Services- Physician (Top)

When lack of diagnostic certainty ( e.g. chest pain, head injury) or some additional therapeutic treatment (e.g. asthma, CHF evaluation) could prevent an inappropriate inpatient admission, consider Observation services. Observation is not a place, but an outpatient status and can occur in the Emergency Department by the ED Provider. Observation services require an order, "Admit to Observation", periodic progress note(s), and a brief discharge plan/summary. When disposition is uncertain, and estimated length of stay is less than 48 hours, consider admitting to OBS. For additional information on Observation, see the Frequently Asked Questions.

Observation Discharge Services

When Observation status requires an overnight stay with two calendar dates of service, don't forget to document a brief discharge summary note the following day. Observation care discharge (CPT^® 99217) is a separately billable service from Initial Observation (CPT^® 99218-99220). Observation discharge services include a final exam, discussion of the observation stay, follow-up instructions, and preparation of discharge records.

Observation or ED E/M Levels?

If you are not sure whether it is worth the extra effort to document Observation services, consider this:

Visit Level	RVU
99285	4.93 ED Comprehensive History, Exam, and High MDM
99220 + 99217	7.29 Initial Obs Day 1, Discharge Obs Day 2
99236	6.13 Same Day Obs Admit/Discharge (min. 8 hours for Medicare)

Remember that Observation codes 99219-99220 and 99235-99236 each require documentation of all three of past medical, family and social history for reporting Observation services.

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Physical Exam (PE) Requirements (Top)

Electronic medical records should demonstrate patient-specific exam detail and especially location specific details. 99281 through 99284 physical exam documentation requirements can be fulfilled with either Body Areas (Head, Chest, Abdomen, Neck, Back, Genitalia, Each Extremity) or Organ Systems (Constitutional, Eyes, ENT, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Skin, Neurologic, Psychiatric and Hematologic/Lymphatic/Immunologic). 99285 requires a comprehensive exam which is considered to be a minimum of eight organ systems examined and documented.

For 99285 if your exam note is organized by body areas, make sure that organ systems are identifiable in your PE documentation. For example, head “normocephalic and atraumatic” does not neatly convert into organ systems. If other exam notes describe organ systems including musculoskeletal and skin, then there is no real documentation benefit for “Head: normocephalic and atraumatic.” Best practice is to document exam of scalp, eyes, ENT, and describe whether there are or are not abrasions, lacerations, contusions, dental caries, etc. as appropriate.

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