Volume 1, #2

August 2004

In this issue:

• Coding News
  • Documentation 101 for Coding ED Facility Services
• Compliance Corner
  • CMS Releases 2005 Outpatient Prospective Payment System (OPPS) Proposed Rule Changes

Coding News

Documentation 101 for Coding ED Facility Services

Candace E. Shaeffer, RN, MBA, RHIA
Vice President, Coding Operations/Quality Management

Effective nursing documentation in your Emergency Department is important because optimal ED reimbursement is based on accurate code assignment and accurate code assignment is dependent on effective nursing documentation. 

CMS, the Centers for Medicare and Medicaid Services, has stated that they will develop facility documentation guidelines for ED and hospital based clinics. The 2005 OPPS Proposed Rule, published earlier this month in the Federal Register, contains no new guidelines so the earliest we can expect implementation of a new standard is in 2006. Absent specific directions from licensing, regulatory, and accreditation agencies, in 2001 LYNX devised an acuity and resource based coding algorithm to meet the general guidelines published by CMS. When coding and charging for facility visits in your ED, LYNX employs this point system to evaluate the level of service provided during each ED encounter. The coder reviews your documentation and assigns the appropriate code — 99281-99285 or critical care.

In order to determine the accurate visit level, LYNX coders assess the patient’s presenting problem and documentation in five categories of service provided and documented by ED nursing and ancillary staff.  Points are assigned for the presenting problem (base weight) which includes the routine work of registration, triage, routine vital signs, general patient communication and routine discharge instructions.  The additional categories of service for point assessment include mode of arrival, order management, process management, nursing assessment and disposition. ED record documentation is evaluated for work performed in these categories and if found, coders add “resource points” to the base weight. The final visit level is determined by calculating the total points and comparing them to the point ranges designated for each level of service.

It is important that the ED clinical record contains documentation of the following data elements for each patient seen:

1. Mode of Arrival — Document whether the patient arrived by ambulance, police or medic unit. Not all ambulance arrivals are treated equally on arrival. ALS en route to the ED may range from providing medications to stabilize a problem all the way to managing a patient in cardiac arrest. These details need to be included in the nursing or physician’s documentation.
 
2. Order Management — Additional resources are required to management orders between hospital departments (such as lab, radiology, etc.). Any clinical orders that must be coordinated with another department should be clearly documented.
 

3. Process Management — Additional resources are required in certain situations to coordinate with other medical personnel or to manage a patient with resource-intensive or special needs. Additional points may be added for these services and ED staff should document the following:

   • Physician consults where a consulting physician (including residents) sees the patient in the ED and the staff performs additional work to manage the patient.
   • Consults with other staff such as social workers or other support staff employed by the hospital who see the patient in the ED.
   • A social or psychological crisis that occurs in the ED refers to management of a patient with an emotional or behavioral issue that significantly impacts the commitment of staff time.  An extreme example would be an abusive, intoxicated patient requiring security and ED staff to manage the situation. Another example is a suicidal patient on a frequent monitoring schedule.
   • Restraints which impact staff time and resources. ED/hospital policy documentation requirements should be followed.
   • Patient impairments that affect patient management in the ED. Examples include a hearing-impaired patient requiring extra management time related to communication, obtaining an interpreter, etc. or close monitoring of a confused patient who is not physically restrained.  
4. Nursing Assessments — Nurses assess patients continually but this care is not always documented. Coder’s evaluate the number and quality of nursing notes to determine if resource points should be added. They look for nursing notes that are timed and provide patient clinical information (assessment data.) Notes such as “to x-ray” or “patient discharged” are not considered when determining ED visit level as these are included in the base weight.
 
5. Disposition — A disposition that adds extra resource points is one where care is continued after the ED or requires extensive time. Documentation should clearly state any time a patient is admitted, immediately referred to a physician’s office for consultation or treatment or is transferred to another hospital. Any factor that increases nursing time, such as arranging for portable oxygen and/or a monitor during transfer or nursing staff being required to assist in transfer because of special circumstances, etc. should be documented.

Critical Care

Critical care is a unique level of service. Unlike the other levels of service, it has a minimum time requirement before it can be assigned. Management of a critical care patient requires a significant amount of additional services compared to the normal level 5 visit. In these exceptional cases, the additional resources will add sufficient resource points to meet critical care point requirements. In addition to points, the duration of the critical care service must total 30 minutes or greater. This time can be documented in the nurse’s or the physician’s notes.

Procedures

Many ED procedures are reimbursed separately in addition to the visit level therefore all procedures should be documented as thoroughly as possible. For example, there are separate codes for injecting an antibiotic versus injecting another medication, for administering it IM versus IV, and for managing an IV infusion.  Some procedures may not be separately reimbursable but may add points if clinical patient information is documented (see nursing assessment above). An example is documentation related to the nurse’s assessment of the patient’s clinical status in relation to an IV. This might include assessment of the IV site (infiltration, complaint of discomfort at the site, redness, etc.) or how the patient is tolerating the infusion (generalized discomfort or checking the lungs for fluid overload, etc.).

Documentation

In most states there are rules and regulations that specify what should be contained within a medical record. Many regulations simply specify that the record must be “complete” or “adequate.”  Internal hospital policies and procedures are often set with the accreditation and regulatory guidelines in mind. The standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) states:

“an adequate medical record be maintained for every person evaluated or treated as an inpatient, an outpatient, an emergency patient or a patient in a hospital care program. The record must contain sufficient information to identify the patient, support the diagnosis and treatment, and it must furnish adequate documentation of results. A medical record should be produced and maintained on every patient seeking emergency care and should be incorporated into the patient’s permanent hospital record.”

According to Washington state and JCAHO documents (prior to the transition to functional areas), each time a patient visits the Emergency Department, the following information should be entered in the patient’s medical record:

• Means of arrival and nature of complaint
• Pertinent history of the illness or injury, and physical findings, including the patient’s vital signs
• Emergency care provided prior to patient arrival
• Diagnostic and therapeutic orders
• Clinical observations, including the results of treatment and the patient’s response to care
• Reports of procedures, tests and results
• Diagnostic impression
• Referrals and communications made to internal or external providers and to community agencies
• Conclusion at the termination of evaluation/treatment, including final disposition and time, discharge instructions and of the patient’s condition on discharge or transfer 
• A patient’s leaving against medical advice.

In addition, JCAHO states that “all entries must be legible and complete and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing or evaluating the services furnished.”

ED Specific Documentation Content

When documenting the History and Triage Information, it is important to always elicit and document the patient’s presenting problem(s) in his or her own words. Additional history relevant to the presenting problem, issues that might impact the patient’s healthcare and an initial exam should be documented as well. This information will help to determine the severity of the patient’s problem, establish the medical necessity for the emergency department visit, and allow the nursing staff to plan the care and interventions that may be required to care for the patient.

Careful documentation of the ED Course, including nursing assessment, interventions and disposition of the patient, should reflect the extent of nursing care provided, support the patient’s acuity, and allow coders to accurately assign the codes that reflect services provided during the ED encounter. This documentation will support correct coding of the visit level and any separately billable procedures that were performed during the course of the ED visit.

The ED physician or other provider will document ED orders on the clinical record or order sheet. Internal hospital or departmental polices will dictate correct “noting” and documentation of order completion. In order to assign a code for a separately billable procedure there must be documentation that the procedure was ordered, that it was medically necessary and that the nurse, a physician or other ED staff performed the procedure.

When a nursing, diagnostic or therapeutic/surgical procedure is performed, there should be clear documentation in the medical record of what was done, the outcome and any follow-up, if appropriate.  Examples include surgical procedures that the physician performs such as laceration repairs, fracture care and lumbar punctures; diagnostic procedures such as 12 lead ECGs and heart monitors; and nursing procedures such as injections, IV infusions and NG tube insertions. Some procedures have very detailed and specific documentation requirements in order to code the service, an example is conscious sedation.

Documentation feedback will be provided by LYNX coders when the documentation does not support the expected visit level or if a procedure is inadequately documented. 

If you have questions about the documentation required for optimal coding, your LYNX coding manager is available to work with you and your ED nursing staff.

Compliance Corner

CMS Releases 2005 Outpatient Prospective Payment System (OPPS) Proposed Rule Changes

By Ann Florer, RN, CCS-P
Coding Compliance Manager

ED and Clinic Levels

Many experts thought this would be the year that CMS would adopt National E/M Coding Guidelines for Emergency Department and clinic E/M levels.  CMS states they are still considering the proposed guidelines of an independent expert panel composed of members of the AHA and AHIMA, ACEP, ENA and the American Organization of Nurse Executives. CMS will not implement new E/M codes until they are also ready to implement guidelines for their use. CMS reiterated that “to facilitate proper coding, we require each hospital to create an internal set of guidelines to determine what level of visit to report for each patient.”  LYNX Facility Coding Algorithm provides this internal guideline for our facility clients.

Observation Rules

CMS is recognizing the unreasonable reporting burden providers have encountered trying to report clean claims when separately payable observation services are provided. Hospitals have indicated they must often do manual reviews to prepare the claims. The proposed rule change will remove the requirement for specific diagnostic testing, such as two sequential 12 lead EKG’s or CPK/Troponin levels. The proposed rule indicates that CMS will not be expanding the conditions for which separate observation services are paid from the current three (CHF, Asthma and CHF) at this time.

Medication Infusions and Blood Products

Other proposed changes include using CPT codes for drug administration (infusion and chemotherapy) rather than “Q” codes. Although the proposal is to crosswalk the CPT code to the current APC, this method change would allow CMS to have different cost data on the different types of infusion services provided and may result in improved payment for drug administration services by 2007. Also included is a proposal to establish new APCs that would allow each blood product to be its own separate APC.

To read the proposed rule in its entirety, please click here: CY 2005 Hospital Outpatient Prospective Payment System