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About Ted Fan, MD

Emergency Medicine Chief Resident
Department of Emergency Medicine
George Washington University

ED Charting and Coding: Critical Care Time

After a STEMI activation from the field on Monday morning, the cardiac catheterization team scoops the patient away shortly after the paramedics arrive in the Emergency Department (ED). “Well that was a smooth and seamless resuscitation. The patient was barely in the ED for more than 15 minutes,” you think to yourself. You diligently complete your critical care documentation, noting 20 minutes of critical care time, before seeing your next patient. A few weeks later the chart is bounced back and noted as an erroneous documentation of critical care time. The coding department notifies you that the case will be billed as a Level 3 visit (E/M code #99283). Why is that the case?

(more…)

By |2019-02-19T18:51:56-08:00Jul 17, 2017|Administrative, Critical Care/ Resus|
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ED Charting and Coding: Physical Exam (PE)

computer-charting-TEXT-canstockphoto17902161

Editor’s Note (Jan 13, 2023):

The new AMA CPT 2023 Documentation Guidelines have been published and the prior physical elements are no longer incorporated into the billing and coding guidelines. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

“What do I see, hear, and smell when I walk into the room?” While the oral boards challenge you to perform the physical exam in a certain way, the day to day examination of patients can vary dramatically. Centers for Medicare and Medicaid Services (CMS), however, has physical exam guidelines for billing that conform to neither the exam you learned as a medical student nor the one you’ve refined as a resident. These disparities between what you do and how you’re asked to document it can lead to charts that are frequently down-coded or at risk if audited. The following discussion tries to unravel some of these twisted regulations and will provide tips and tricks on how to improve your physical exam documentation for coding and billing.

Double Standards

“There are no straight backs, no symmetrical faces, many wry noses, and no even legs. We are a crooked and perverse generation.” – Sir William Osler

There are 2 very different standards used to bill CMS and/or insurance companies: the 1995 and 1997 CMS guidelines. Overall, 1995 is too vague, 1997 is too specific, and the responsibility to choose one or the other falls on your coding department.

The 1995 guidelines identify Body Areas and Organ Systems as a framework for documenting the physical exam, but do not say what to chart under either.

The 1997 guidelines define mandatory physical exam elements and called them Bullets. A comprehensive exam requires all bulleted items to be examined, and at least 2 per system to be documented. The full list of bullets is in the appendix at the end of this post. These guidelines also describe Single Organ System examinations, which focus on a primary organ system but require bullets from other systems. Don’t bother looking these up– in general, a comprehensive single organ system examination is more complicated to perform and document than a comprehensive multi-system exam.

physical-exam-em-level

* 1995 guidelines allow a combination of systems & body areas for PF, EPF, & Detailed exams.  ** 1997 multi-system exam requires specific bullets for each system.

Work Smarter, Not Harder: Resuscitating the Physical Exam

  • Develop a structured, comprehensive exam that you can perform on nearly any patient, and use the normal findings for this exam as your documentation template. If your department uses the 1997 guidelines, read through the bullets and pick 2 per system to include in your exam.
  • Your examination is part of your decision making. The chief complaint will indicate certain positive or negative findings to be documented.
  • With many EMRs, vital signs are usually automatically pulled into your note. In addition to reviewing all vitals as part of good patient care, include a statement in your documentation that the recorded vital signs were reviewed.

Sample template for normal comprehensive physical exam

Vital Signs: P / BP / RR / SpO2 / T [1]
I have reviewed the triage vital signs.

  1. Const: Well-nourished, Well-developed (WNWD), Young/Middle-Aged/Elderly Male/Female appearing stated age [2].
  2. Eyes: PERRL [1], no conjunctival injection [2], and symmetrical lids [3].
  3. ENMT: Atraumatic external nose and ears [1]. Moist MM [2].
    * Neck: Symmetric, trachea midline [1], No thyromegaly [2].
  4. CVS: +S1/S2, No murmurs or gallops [1]. Peripheral pulses 2+ and equal in all extremities [2].
  5. RESP: Unlabored respiratory effort [1]. Clear to auscultation bilaterally (CTAB) [2].
  6. GI: Nontender/Nondistended (NTND) [1], No hepatosplenomegaly (HSM) [2].
  7. MSK: Normocephalic/Atraumatic (NC/AT) [1], Extremities w/o deformity or ttp [2]. No cyanosis or clubbing [3]
  8. Skin: Warm, Dry [1]. No rashes or lesions [2].
  9. Neuro: CNs II-XII grossly intact [1]. Sensation grossly intact [2].
  10. Psych: Awake, Alert, & Oriented (AAO) x3 [1]. Appropriate mood and affect [2].

The 10 listed items are for both the 1995 and 1997 guidelines. The bracketed red numbers are the bullets for the 1997 guidelines. The * counts as a system/area in the 1997 guidelines.

Final Tips

  • Although technically acceptable under 1995 guidelines, avoid charting only “normal” or “abnormal” under a system, instead list specific abnormal or pertinent normal findings.
  • Find out which guidelines your coders use: the list of organ systems is mostly the same, but the 1997 rules require far more specific information.
  • From an ethical and medical legal perspective, if you document it, examine it! Tailor your smart phrases or macros to a list of normals you reliably perform on every patient, every time, and include placeholders for you to add patient-specific information.
  • If your department utilizes scribes (or incorporates medical student notes), take an extra second to review their documentation for completeness and accuracy.

Additional Reading

[su_spoiler title=”Appendix: Full list of Organ Systems and Body Areas” style=”fancy” icon=”caret”]

The following 12 Organ Systems are the same in the 1995 and 1997 Guidelines, with the 1997 Bullets listed for each:

Constitutional

  • Vital Signs (any 3 of the following): sitting or standing BP, supine BP, pulse rate & regularity, respiration, temperature, height, weight
  • General Appearance, e.g. development, nutrition, body habitus, deformities, attention to grooming

Eyes

  • Conjunctiva & Lids
  • Pupils & Irises: size, symmetry, reaction to light, accommodation
  • Ophthalmologic examination of optics discs and posterior segments

Ears, Nose, Mouth, Throat (ENMT)

  • External inspection of ears and nose
  • External auditory canal & tympanic membranes
  • Assessment of hearing
  • Nasal mucosa, septum, & turbinates
  • Teeth, lips, & gums
  • Oropharynx: mucosa, salivary glands, hard/soft palate, tongue, tonsils, posterior pharynx

Cardiovascular (CVS)

  • Palpation: location (PMI), size, thrills
  • Auscultation: heart sounds & murmurs
  • Carotid arteries: pulses amplitude, bruits
  • Abdominal aorta: size, bruits
  • Femoral arteries: pulse amplitude, bruits
  • Pedal pulses: pulse amplitude
  • Extremities for edema and/or varicosities

Respiratory

  • Respiratory effort, intercostal retractions, accessory muscle use, diaphragmatic movement
  • Percussion of chest: dullness, flatness, hyperresonance
  • Palpation of chest: tactile fremitus
  • Auscultation of lungs: breath sounds, adventitious sounds, rubs

Gastrointestinal (GI)

  • Abdominal masses or tenderness
  • Liver & spleen
  • Presence or absence of hernia
  • Anus, perineum, rectum including sphincter tone, presence of hemorrhoids, rectal masses
  • Obtain stool for fecal occult blood test (FOBT)

Genitourinary (GU) – Male

  • Scrotal contents: hydrocele, spermatocele, tenderness of cord, testicular masses
  • Penis
  • Digital rectal exam (DRE) of prostate: size, symmetry, nodularity, tenderness

Genitourinary (GU) – Female

  • External genitalia and vagina: general appearance, discharge, lesions, pelvic support, cystocele, rectocele
  • Urethra: masses, tenderness, scarring
  • Bladder: fullness, masses, tenderness
  • Cervix: general appearance, lesions, discharge
  • Uterus: size, contour, position, mobility, tenderness, consistency, descent or support
  • Adnexa/parametria: masses, tenderness, organomegaly, nodularity

Musculoskeletal (MSK)

  • Gait & station
  • Inspection and/or palpation of digits and nails
  • Joints, bones, muscles: one or more of the following 6 areas: head/neck, spine/ribs/pelvis, right upper extremity (RUE), left upper extremity (LUE), right lower extremity (RLE), left lower extremity (LLE)
    • Inspection and/or palpation: deformities, asymmetry, crepitus, tenderness, masses, effusions
    • Range of motion (ROM) w/ notation of pain, crepitus, contracture
    • Stability w/ notation of dislocation/luxation, subluxation, or laxity
    • Muscle strength & tone (flaccid, cog wheel, spastic) w/ notation of atrophy or abnormal movements

Skin

  • Inspection of skin & subcutaneous tissues: rashes, lesions, ulcers
  • Palpation of skin & subcutaneous tissues: induration, nodules, tightening

Neurologic

  • Cranial nerves w/ notation of deficits
  • Deep tendon reflexes (DTRs) w/ notation of pathological reflexes (Babinski)
  • Examination of sensation: touch, pin, vibration, proprioception

Psychiatric

  • Insight & judgement
  • Brief assessment of mental status
    • Orientation to time, place, & person
    • Recent & remote memory
    • Mood & affect: depression, anxiety, agitation

Hem/Imm/Lymphatic

  • Palpation of nodes in 2 or more areas: neck, axillae, groin, other
1997 guidelines include two additional Organ Systems
Neck

  • Overall appearance, masses, symmetry, tracheal position, crepitus
  • Thyroid: enlargement, tenderness, masses

Chest (including breast and axillae)

  • Inspection of breasts: symmetry, nipple discharge
  • Palpation of breasts & axillae: masses/lumps, tenderness
Body Areas – used by the 1995 Guidelines
Head (including face)
Neck
Chest (including breast and axillae)
Abdomen
Genitalia, groin, buttocks
Back (including spine)
Extremity (each extremity counts as one body area)

[/su_spoiler]

By |2023-01-13T18:40:12-08:00Nov 9, 2016|Administrative|
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ED Charting and Coding: History of Present Illness & Past Medical, Family, Social History

Editor’s Note (Jan 13, 2023): 

The new AMA CPT 2023 Documentation Guidelines have been published and the prior history and physical elements are no longer incorporated into the billing and coding guidelines. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

medical chart history of present illnessRemember the “OPQRST” mnemonic? It stands for Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing. Not only can it guide your history taking, but charting these descriptors also ensures you can code at an appropriate level. The patient’s history is the first example of the balance between essential information and over-documentation. It should be comprehensive, yet be chief-complaint focused [1]. Below, we outline the components of a thorough and billable history.

History

The history includes 4 elements:

  1. Chief complaint (CC)
  2. History of present illness (HPI)
  3. Review of systems (ROS)
  4. Past medical, family, and social history (PFSH)

A chief complaint is required for all levels of charting. The remaining three elements (HPI, ROS, PFSH) determine the type of history for the chart, as separated into 4 levels [2,3]:

  1. Problem Focused
  2. Expanded Problem Focused
  3. Detailed
  4. Comprehensive

The lowest common history level met by all elements determines the highest billable Evaluation and Management (E/M) level.

Remember “4-2-1” rule: 4 descriptors for HPI, 2 sections of PFSH, and 1 item per system for ROS guarantees a Comprehensive history.

E/M LevelHistory TypeHPIROSPFSH
IProblem Focused1-300
II/IIIExpanded Problem Focused1-310
IVDetailed42-91/3
VComprehensive410+2/3

Example: 

If the HPI and ROS meet requirements for a Comprehensive History (E/M level 5) but the chart does not include any elements from the PFSH, this limits the history to Expanded Problem Focused. You can not bill higher than an E/M level 3.

Chief Complaint (CC)

Centers for Medicare & Medicaid Services definition:

“A concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s own words.”

A clearly stated CC may be documented in a physician’s note or a triage note [2].

History of Present Illness (HPI)

The HPI discusses details of the CC and provides a chronological story, usually with 3-4 of the following descriptors [1,2]:

  • Location
  • Quality
  • Severity
  • Duration
  • Timing
  • Context
  • Modifying factors
  • Associated signs/symptoms

A Brief HPI (E/M levels 1-3) requires 1-3 descriptors, while an Extended HPI (E/M levels 4-5) requires ≥4 descriptors [2,3]. Note that E/M level 4-5 charts can still be concise.

Example

The patient is a 34 y/o M presenting with chest pain (chief complaint) that is substernal (location), starting an hour prior to arrival (duration) while mowing the lawn (context), feels “like a pressure” (quality) that is intermittent (timing) and severe (severity), with associated nausea and diaphoresis (associated signs/symptoms).

This qualifies for Comprehensive, E/M Level 5 with 8 HPI descriptors.

Review of Systems (ROS)

Keep your eye out for our next post, where we will dive into the complexities of ROS.

Past Medical, Family, and Social History (PFSH)

Past Medical History (PMH) includes chronic diseases, past illnesses/injuries, and operations/treatments. Family History (FH) is a review of medical events including hereditary and non-hereditary disease. Social History (SH) is a review of pertinent age-appropriate current and past risks factors such as alcohol/tobacco/drug use, sexual history, employment, and education. You must document one specific item for a Detailed history (E/M level 4) and at least one item each in two areas for a Comprehensive history (E/M level 5) [2,3].

Example for Detailed History, E/M level 4

  • PMH: Hypertension, hyperlipidemia, diabetes mellitus. [Detailed, E/M level 4]

Example for Comprehensive History, E/M level 5

  • PMH:Hypertension, hyperlipidemia, diabetes mellitus
  • SH: smokes cigarettes 1 ppd

A common misconception is that listing two past medical problems (e.g. hypertension, diabetes) are still all counted as two items. They are instead all under one item (PMH). You still need to list an item from either the SH or FH to be eligible for E/M level 5. Thus this would drop the coding from a potential E/M level 5 down to a level 4.

The PMFH recorded by ancillary staff (e.g. tobacco use recorded at triage as part of the SH) counts as long as it is included in your documentation with a statement of review and confirmation [1]. Example: “Past medical, family, and social histories reviewed and verified by me.”

Additional Tips

  1. CC, ROS, and PFSH may be recorded by ancillary staff or via patient questionnaire, but you must document that you have confirmed this information with the patient [2,3].
  2. What if a patient is unconscious, intubated, or refuses to give a history? If a patient’s condition or circumstance limits acquisition of any history component, add a qualifier describing the limitation, e.g. cannot obtain due to encephalopathy, dementia, intubation, etc. This qualifier applies to all elements of history: HPI, ROS, and PFSH [2,3]
  3. Did you play detective and obtain a history through other sources? Get credit! As an alternative to the extended HPI (E/M level 5 HPI), you can discuss the status of at least 3 chronic or inactive conditions [1,2]

Example: Patient sent from nursing home for altered mental status. He is nonverbal at baseline, but per nursing staff and transfer records, his (1) urinary retention has been stable with Foley in place, he (2) has not missed any seizure medications, and (3) the staff has been controlling his blood glucose well.

A statement describing how and what additional history was obtained will add to the complexity of data review in your medical decision making (MDM), which will be detailed in a later post). The statement “Additional history obtained by family/extended care facility staff” without elaboration will not count [2].

Work Smarter, Not Harder

The elements above describe the minimum data for each level. It is important to include additional data as appropriate and to avoid potential down-coding; however, be cognizant of wasting time or space recording historical information which neither contributes to your thought process nor billing. Some items are relevant to many aspects of care: diabetes in the family, bleeding and clotting diatheses, smoking history, and illicit drug use are both PFSH and risk factors. A patient’s living situation is relevant for disposition. Do not include “not relevant” or “non-contributory” history as it does not contribute to billable documentation.

See the PV Card on ED Charting and Coding

References

  1. Guth T, Morrissey T. Medical Documentation and ED Charting. CDEM Curriculum. 2015. Accessed 30, 2016.
  2. 1997 Documentation Guidelines for Evaluation and Management Services (PDF). Centers for Medicare & Medicaid Services. Accessed Aug 30, 2016.
  3. Evaluation and Management Services Guidelines (PDF). Department of Health & Human Services: Centers for Medicare & Medicaid Services. Accessed Aug 30, 2016.


(c) Can Stock Photo

By |2023-01-13T18:35:53-08:00Sep 5, 2016|Administrative|
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PV Card: Introduction to ED Charting and Coding

Editor’s Note (Jan 13, 2023): 

The new AMA CPT 2023 Documentation Guidelines have completely revamped how the billing and coding for Emergency Department charts is done. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

ED charting and coding computer-charting-TEXT-canstockphoto17902161What makes a good chart? How do you write a good chart quickly? How about a good, efficient, billable chart? On average, residents and practicing physicians report they did not receive adequate training in charting and coding [1–3] and resident charts are more often down-coded due to documentation failures than those of attendings and PAs [4]. Thankfully, resident education in charting has improved over the past 15 years [5], and a little learning goes a long way to improve confidence [6] and competence [7].

In the spirit of #FOAMed, we would like to provide some pearls and pitfalls for EM documentation, starting with a PV card that addresses the basic elements of coding a chart. We hope it’s a handy on-shift reference.

What is a CPT code? What is an E/M level?

In order to uniformly bill for services provided, the American Medical Association (AMA) maintains a list of Current Procedure Terminology (CPT) codes. When you provide medical services to a patient, the chart is billed using a CPT code based on Evaluation & Management (E/M) levels 1-5 [8]. Most ED visits are billed as E/M levels 3-5. In order to objectively categorize a chart, Centers for Medicare & Medicaid Services (CMS) created a coding system to assign an E/M level.

What is the difference between a lower and higher E/M level chart?

Three essential elements determine the E/M level: history, physical exam, and medical decision making (MDM). Each of these components is evaluated by a set of guidelines and categorized by the documented elements of the history/physical exam and complexity of MDM. After evaluating each essential element separately, all three are considered in choosing an E/M level and CPT code that is billed. The complexity of your MDM should ultimately determine your E/M level, but under-charting in another area will limit you from billing an appropriately high E/M level.

On your next shift, take a second to review your charts. Could one additional word in the history of present illness (HPI) bump a level 3 up to a level 4? Did you mention your chart biopsy, even if it was just skimming the most recent discharge summary or yesterday’s note? The following PV card outlines the minimum elements needed from all 3 areas required to code specific E/M levels, and shows that a single word or phrase may be the difference in clarifying a higher level of care provided.

Keep an eye out for our follow-up posts. We’ll focus on individual sections of the chart (history, physical examination, MDM), specific diagnoses and special situations that require extra care when documenting.

Happy charting!

References

  1. Howell J, Chisholm C, Clark A, Spillane L. Emergency medicine resident documentation: results of the 1999 american board of emergency medicine in-training examination survey. Acad Emerg Med. 2000;7(10):1135-1138. [PubMed]
  2. Pines J, Braithwaite S. Documentation and coding education in emergency medicine residency programs: a national survey of residents and program directors. Cal J Emerg Med. 2004;5(1):3-8. [PubMed]
  3. Dawson B, Carter K, Brewer K, Lawson L. Chart smart: a need for documentation and billing education among emergency medicine residents? West J Emerg Med. 2010;11(2):116-119. [PubMed]
  4. Ardolic B, Weizberg M, Cambria B, et al. 362: Documentation and Coding Skills: Is There Adequate training in Emergency Medicine Residency? Ann Emerg Med. 2006;48(4):108.
  5. Heiner J, Dunbar J, Harrison T, Kang C. 426: Current Emergency Medicine Residency Education of Documentation, Coding, and Reimbursement: Fitting the Bill? Ann Emerg Med. 2010;56(3):137-138.
  6. Takacs M, Stilley J. 169: Billing and Coding Shift for Emergency Medicine Residents: A Win-Win-Win Proposition. Ann Emerg Med. 2015;66(4):60.
  7. Carter K, Dawson B, Brewer K, Lawson L. RVU ready? Preparing emergency medicine resident physicians in documentation for an incentive-based work environment. Acad Emerg Med. 2009;16(5):423-428.
  8. Evaluation and Management Services Guidelines. Dept of Health & Human Services: Centers for Medicare & Medicaid Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. Published August 2015. Accessed July 24, 2016.
By |2023-01-13T18:42:49-08:00Aug 15, 2016|Administrative, ALiEM Cards|
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