Emergency Medicine Documentation Review

2020

Documentation Provides• Proof of the delivery of quality patient care

• Better protection medico-legally

• Ability to ensure accurate billing and reimbursementthrough practices that comply will all laws, rules andregulatory guidelines

• Communication with colleagues.2

EM DOCUMENTATION GUIDELINES - CPT & CMSE & M Nature of

Presenting Problem

CPT Nomenclature

CMS Quantification

RVU 2020

99281 Minor;self limited

Problem focused HxProblem focused Exam Straightforward MDM

1 HPI- 0 ROS- O PFS Hx1 Organ system examStraightforward MDM

0.64

99282 Low Expanded problem focused HxExpanded problem focused Ex Low Complexity MDM

1 HPI-1 ROS-0 PFS Hx2 Organ system examLow Complexity MDM

1.23

99283 Moderate Expanded problem focused HxExpanded problem focused ExModerate Complexity MDM

1 HPI-1 ROS-0 PFS Hx2 Organ system examModerate Complexity MDM

1.84

99284 High Detailed HxDetailed ExamModerate Complexity MDM

4 HPI- 2 ROS- 1 PFS Hx2+ Organ System ExamModerate Complexity MDM

3.38

99285 High Comprehensive HxComprehensive ExamHigh Complexity MDM

4 HPI- 10 ROS- 2 PFS Hx8 organ system examHigh Complexity MDM

4.91

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Determine the Extent of H & P

•Medical Necessity of a service is theoverarching criteria for payment in addition tothe individual requirements of a CPT Code

“Medical necessity is defined as accepted health care services and supplies provided by health care entities, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care.”

“Medicare Claims Processing Manual Chapter 12, Section 30.6.1”

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Evaluation and Management Services

1.) History- includes Chief complaint, HPI, ROS, and PFSH

2.) Physical Exam

3.) Medical Decision Making

• All three components must be met in order to assign an EmergencyMedicine evaluation and management code 99281 - 99285

• Medical decision making is the key determining factor for the E/Mcode selection

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Medical Decision MakingIncludes but not limited to:✓Document your differential diagnosis✓Ordering, reviewing &/or interpreting test/images✓Consultations with other health care providers-Document who and

briefly what was discussed✓Meds given or prescribed✓Is the problem improving/resolving or worsening/failing to change

as expected✓Order, Review and Summarization of old records: Document

pertinent/ relevant information needed to manage your patient fortoday’s visit. (HPI or MDM)✓Diagnosis/Diagnoses & Disposition

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Discussions With Other Healthcare ProvidersDocument any and all discussions of case with other healthcare providers to include both of the following: 1. Who you consulted with: name of provider or ortho, hospitalist, admitting

physician, social worker, neuro, etc.AND

2. Brief Statement of what you discussed.

Example Format: I discussed /consulted with the provider name or ortho, hospitalist, admitting physician, social work, psych, neuro, etc. and a brief statement of what you discussed.

ECGs Best Practice

Interpreted by me/Read by me/ Direct Visualization by me or ED physician + plus 1 finding.• Rhythm

• Axis Interval

• QRST wave comments Rate

• Acute or chronic changes

• Comparison with the most recent tracing

• Clinical findings and/or diagnosis

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X-Ray Documentation• If ED Physician/APP interprets film by independently

viewing the images document:

“I have interpreted/read/directly visualized the radiology images (name of image) with one finding.”

• If you review radiologists images document:

“ I have reviewed the radiology images and agree/disagree with the radiologist interpretation +/-discussion with radiologist.”

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OLD RECORDS & STATE DRUG MONITORING PROGRAMDocument:

• Order/Retrieval

• Review/Summarization of Pertinent data

• Where to document: HPI or MDM

Examples:

• Old records: "Reviewed plan of care/treatment plan for 10-1-15 and 11-2-15" or

• Old Records: Compare prior chest X-Ray of 10-5-15 with no changes.

• Accessed Prescription Monitoring Program and 1) No RX on file or2)Last RX filled on____ (insert date(s))

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High Risk Patients (99285) - 4 HPI-10 ROS-2 PFSH-8 OSE

• Decision to admit/transfer/ observation• Administration of parenteral controlled substances• Two or more special studies (CT, US, MRI, MRA, VQ Scan)• Three or more IV or IM/SQ meds• Combination of IV fluids, with IV med or IM/SQ med with 3 or more ancillary

studies and a special study (CT, US, MRI, MRA, VQ Scan)• 4 or more ancillary studies plus one of the following:

- ABG- BLOOD CULTURES- IV FLUIDS AND IV/SQ MEDS- TWO OR MORE NEBULIZERS

Potential Indicators to consider Moderate High Risk 99284 = 4 HPI + 2 ROS + 1 PFSH+ 3 organ system exam

• 2 or more meds given in nebulizer

• 2 or more IM Meds given

• Any 3 of splint, lab, x-ray, rx meds given in ED

• IV fluids

• IM Med given w/ lab, x-ray or breathing tx

• Combination of a fever 100.5, meds given and rx given

• Pelvic or rectal w/ any abdominal pain patient

CC & History of Present Illness - HPI

• HPI requirements per Level ofService:

• 99284 4+ elements• 99285 4+ elements• Must be documented by the

physician or midlevel provider;coders can not use HPIdocumented by nursing staff orother staff

• History Limited Unobtainable:Document Why:

• Examples: Clinical Acuity, AMS,unreliable, appears to under theinfluence, answer yes to allquestions, refuses to answer.

• Location• Quality• Severity• Duration• Timing• Context• Modifying Factors• Associated Signs &

Symptoms

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Review of SystemsRequirements:

• 99284 2+ review

• 99285 10+ review

• “ All other systems reviewed & are negativeexcept where documented below” or “All othersystems negative” &

• Pertinent (+) or (-) findings must be documented

• Document if you review nurse/triage notes sowe can utilize any ROS or PFSH documented bynursing.

• Constitutional

• Eyes

• ENMT

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• MS

• Integumentary

• Neuro

• Psychiatric

• Endocrine

• Hematologic/Lymphatic

• Allergic/ Immunologic

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1) Past Medical/Surgical 2)Family 3) Social History

• 99284 1 OF 3

• 99285 2 OF 3

• CMS Guidelines require: One specific item (+ or -) from a historycategory be documented in order for that category to qualify (I.e.No HX of MI, not a smoker, no family hx of asthma, etc.).

• No Past History: Negative or None indicates you have asked thepatient or caregiver the question

• History Limited Unobtainable: Document Why

Examples: Clinical Acuity, AMS, unreliable, appears to under the influence, answer yes to all questions, refuses to answer.

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Physical Exam

Physical Exam requirements:• 99284 3+ Systems• 99285 8+ Systems

Note Head and Neck –depending upon what is documented can BOTH be musculoskeletal – take caution when “counting” your 8 elements

• Constitutional

• ENT/Mouth – notice these all count as 1

• Eyes

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• Musculoskeletal

• Skin

• Neurological

• Psychiatric

• Hematologic/Immunologic/Lymphatic

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Simple vs. Complicated I & D• Simple / Single I & D

• Complicated I & D

Documentation of one of the following: oDrain or packed

oProbing to break up or exploring loculations

oCulturingoDepth of wound requiring US guidance oMultiple I &D's

Best Practice - In addition to description of I & D Physician/Provider should include when applicable:

"Complicated" or "Complex" in actual procedure note.

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Splint ApplicationBest Practice Document

• Who applies splint by me, by tech, etc.• Type of splint applied• Note Placement check & NV status intact

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Fracture CareDocument:

• Specific Site of the Fracture/Dislocation: Precisely document name

of bone(s)

• Type—Open or Closed

• Treatment—with or without Manipulation/Reduction

• Supportive Immobilization

• Anesthesia

• Reduced/Non-reduced coded with 54 modifier –Surgical Care only

Moderate Conscious Sedation• Time must be documented

• 10 minutes is first threshold

• Intra-service time starts with the administration of the sedation agent(s),

requires continuous face-to-face attendance, and ends at the conclusion

of personal contact by the physician providing the sedation

• Anytime less than 10 minutes is considered part of

procedure.

• Document who the trained observer is.

SIMPLE

• Chemical or electro-cauterization of wounds not closed

• Closure with skin adhesive, staples or suture materials

• 1 suture layer

INTERMEDIATE

• VIP: Single layer closure of heavily contaminatedwound requiring extensive cleaning or removal orparticulate matter.

• 2+ suture layers (deep subcutaneous/non-musclefascia)

Wound Repairs: Document Measurements Accurately. Don’t document “approximately” in recording measurement as you run the risk of being rounded down to a lower suture code.

COMPLEX WOUND REPAIR

In addition to the requirements of intermediate repair listed above, include at least one of the following:

• Exposure of bone, cartilage, tendon, or name neurovascular structure;• Debridement of wounds edges (e.g., traumatic lacerations or avulsions);• Extensive undermining (defined as a distance greater than or equal to the

maximum width of the deficit, measured perpendicular to the closure linealong at least one entire edge of the deficit);

• Involvement of free margins of helical rim, vermillion border, or nostril rim;• Placement of retention sutures.• Necessary preparation includes creation of limited defect for repairs or the

debridement of complicates lacerations or avulsions.

Foreign Body Removal / InstrumentsDocument the use of visual instruments and/or surgical tools—not irrigation or air pressure

• Foreign Body Removal (Ear)E.g., Otoscope—forceps

• Foreign Body NoseE.g., Otoscope—forceps

• Foreign Body CorneaE.g., Slit lamp—fine gauge needle

• Impacted Cerumen-use instrument to remove impacted cerumenE.g., Otoscope—curettes, hooks, forceps to breakup and remove

Impacted Cerumen irrigation/lavage onlyE.g., irrigation /lavage, unilateral document:

Removal of impacted cerumen using irrigation or lavage “performed by me.”• Note: If the physician or mid-level determines there is ear wax, but it is not impacted, the removal (if any) is not

separately reportable and is considered bundled into the evaluation and management service.

Trigger Point Injection(s) Best practice Documentation:

Trigger point injection(s)performed by me and specify the number of muscles ( 1 to 2 or 3 or more) and the muscle names for coders to make the appropriate code selection.

• VIP: It’s not the number of injections rather the # of muscles injected.

Trigger point injection CPT codes:

• 20552:Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

Total RVU 1.11

• 20553:Injection(s); single or multiple trigger point(s), 3 or more musclesTotal RVU 1.25

Critical Care Services (CMS)• Clinical and Treatment Criteria Must be Met to include:

1. Illness or injury that acutely impairs one or more vital organ systems such thatthere is a high probability of imminent or life threatening deterioration in thepatient’s condition.

2. Requires the physician’s or other qualified health care professional’s directdelivery of medical care for the critically ill or injured patient.

3. Medical decision making of high complexity to assess, manipulate and supportvital organ system failure and/or prevent further deterioration of the patient’scondition.

And Medicare Adds:

“… the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration of the patient’s condition.”

ACEP: Suggests to meet CC requirements, answer YES to all 3 questions: 1. Is at least one vital organ system acutely impaired?

2. Is there a high probability of imminent, life-threateningdeterioration?

3. Did you intervene to prevent further deterioration of the patient’scondition?

**In addition to YES, the physician request and time requirement greater than 30 minutes must be met

ACEP: Still unsure? Ask yourself two questions:

1. Was patient admitted (based on medical necessity) toICU or immediate dispo to OR?

a. If yes: strongly consider CCb. If no: is it really CC?c. If no (and you think it is CC): consider a Medical Necessity

note2. Will the patient die or deteriorate (soon) if you don’t dosomething (quickly)?a. If yes: document CC timeb. If no: is it really CC?c. If no (and you think it is CC) : consider a Medical

Necessity note

Medical Necessity statement to include :

• “Organ system(s) at risk is/are…”• Differential diagnosis• “What and why” as far as diagnostic and/or therapeutic

interventions undertaken by YOU• Critical lab, imaging EKG findings documented and

significance addressed• ED Course reflects frequent re-assessments and decision

making• Likelihood of life-threatening deterioration

Documentation suggesting may not be CC• “Stable”, “resolved”, “no active issues”, “no new complications”

and/or “improving.”• Normal VS “Resting comfortably”• Minimally documented and/or benign ED Course that does not

support medical necessity• Abnormal lab values alone do not support CC unless MDM reflects

high complexity MDM and initiation of life-savingassessment/treatment or prevention of serious deterioration

• Maybe: High risk presentation with subsequent r/o of criticalillness/injury

Consider Medical Necessity statement if above scenarios justify CC

Critical Care Time• Minimum of 30 minutes = total duration spent in the provision of

critical care services to a critically ill patient even if time providingcare on that date is not continuous

• 30-74 minutes = 99291; each additional 30 minutes = 99292

• Avoid recording CCT in time ranges. CMS does not accept.

• CCT does NOT include time spent on separately billable procedures

• Document CCT ____minutes excluding separate billable procedures

• PLUS summarize the care you provided in the “critical care” sectionof the chart.

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The Interpretation of:• Cardiac output measurements (CPT 93561,93562)• Chest x-rays (CPT 71045,71046)

Monitoring blood gases, evaluating information stored in computers;• Pulse Oximetry (CPT 94760,94761,94762), blood gases and collection & Interpretation

of physiologic data. eg blood pressures & hematologic data.• Gastric intubation (CPT 43752, 43753)• Temporary transcutaneous pacing ( CPT 92953)• Ventilatory management ( CPT 94002-94004)

AMA/CPT: ANY SERVICES PERFORMED THAT ARE NOT INCLUDED IN ABOVE LISTING SHOULD BE REPORTED SEPARATELY & NOT COUNTED IN YOUR CRITICAL CARE TIME

Time Spent On These Procedures Should Be Included In Your CCT

Examples of Procedures Separately Billable Do not include in your CCT

• Intubation

• CPR Performing & or

Supervising

• Central lines

• Elective Cardioversion

• Chest tube

• Arterial line

• Internal / external pacemakers

• Pericardiocentesis

• Triple lumen catheters

• Thrombolytic injection/infusion

• EKGs

Critical Care – Time – What Counts & Where?

• Immediate bedside or elsewhere on the unit/floor• Reviewing test results or imaging studies (on unit/ floor)• Discussing (on unit/floor) the critically ill patient’s care with other medical

staff • Documenting (on unit/floor) critical care services in medical record• Time spent on the floor/unit with family members/surrogate obtaining

medical history, reviewing pt. condition or prognosis, or discussingtreatment/limitations of, provided that the conversation bears directly on pt. management

• Noncontinous and Continuous time – add it up +; subtract out time spent on billable procedures

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Critical Care Documentation

• Patient’s present condition

• Record any abnormal vital signs

• Which systems are failing or are at high risk to fail

• Document why the services you provided were necessary to prevent life threatening deterioration.

• Caution with auto populated exams

Constitutional: NAD, no respiratory distress. Mild tachycardia

• Differential w/potential testing or tx options =demonstration of high complexity MDM

• Clinical Impression

• Review of Diagnostic data

• Consults

• Discussions with other healthcare providers

• Procedures performed

• Time spent performing procedures that you cannot bill for: • Pulse oximetry, chest x-rays, monitoring blood

gases, evaluating information stored in computers; gastric intubation; transcutaneous pacing; ventilator management & vascular access procedures.

• Interval assessments

• Responses to treatment

• Rationale for treatment= Medical Necessity

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• Patient presents unstable and are stabilized enough to go homewith the caveat that this is a RARE event.

Examples to consider :

1. Diabetes with very high glucose reading requiring insulin dripwith or without initial bolus.

2. Status Asthmaticus, not responding to breathing treatmentsworsening to the point of considering admission or possible ET and patient improves and is sent home.

3. Hypotension, Hypertension (e.g. <70/40 or > ~230/130)

4. Treatment of Hyper/hypokalemia with IV Meds/fluids orelectrolyte placements.

Critical Care – Discharge Patients Possible

Critical Care Medicationsadministered IV unless otherwise specified (not all-inclusive):

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Critical Care Medications

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CC Medications

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RSI (Rapid Sequence Intubation)

Drugs:

Succinylcholine (Anectine™)

Vecuronium

Etomidate

Rocuronium

Norcuron™

Critical Care Vital Signs and Lab Values

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Unstable VITAL SIGNS consistent with organ system failure:

O2 Sat (pulse ox) < or = 90

Respirations (adult/ child) > or = 30

Respirations (adult/child) < 5

Respirations (adult/ child), intercostal retractions, nasal flaring, Cheyne-

Stokes or tachypnea

Temperature (adult) > ~ 104°F

Temperature (adult) < ~ 95°

Heart rate/pulse (adult) > 150

Heart rate/pulse (adult) < 40

Systolic BP (adult) > ~ 230 or < ~ 70

Diastolic BP (adult) > ~ 130 or < ~ 40

Glasgow Coma Score (GCS) < ~ 12

Critical Care Vital Signs and Lab Values

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Other Labs:

ABGs

pCO2 < 20 or >60 mm Hg

pO2 <60 mm Hg

O2 Sat (pulse ox) < or = 90%

pH < 7.25 or > 7.6

Hemoglobin (Hb) < or = 6

Troponin > 0.04 or maximum at specific lab

CK MB > than or = 5%

WBC < 2K or > 20K/μl

Electrolyte Imbalance:

Sodium (Na) < 120 or > 150

Potassium (K) < 2 or > 6.5

Calcium (Ca) < 6 or> 13 mg/dl

Magnesium < 1.5 or > 5 meq/ L

Bicarbonate (C02) < 10 or > 40

meq/L

Platelet count < 20,000

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Paula Allen

allenp@gottlieb.com

Direct: 772.766.2795

Lindsay Frohock

frohockl@gottlieb.com

Direct: 904.710.2572

Tammy Raulerson

raulersont@gottlieb.com

Direct: 904.814.3854

Toll Free: 800.833.9986

Gottlieb Team:Integritas:

If you have coding, billing, or documentation questions, please reach out to us:

Alexandria Morris - amorris@iephysicians.com

Othniel Doolittle, MD - odoolittle@iephysicians.com

Brandy Dagner - bdagner@iephysicians.com