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?
“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.
Remember 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 . Below, we outline the components of a thorough and billable history.
What 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 coding1–3 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 confidence6 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.