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Evaluating and managing hospital E/M services

From the December ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Richard Pinson, MD, FACP

Sidebar: Ask Dr. Pinson: Are clinical signs sufficient for coding?

The documentation required by Current Procedural Terminology (CPT^©) for correct coding and billing of hospital evaluation and management (E/M) services is very complicated and fills the pages of many books. The associated contractual and regulatory requirements could fill many rooms. Still, a basic understanding of the rules, regulations and concepts governing these services can help guide hospitalists on this documentation journey.

The key components of E/M that determine the level of services provided and billable include history, physical exam and medical decision making (MDM), all of which must be documented for every encounter. While in some situations such components as time or coordination of care are the determinative factors, the three key components must still be documented. All documentation and signatures must be legible. Illegible notes are detrimental to patient care and safety; do not meet coding, legal or regulatory requirements; and can be a costly embarrassment if audited or presented in a courtroom.

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Inpatient and observation encounters are classified as initial or subsequent and are based on calendar days. One encounter may comprise multiple visits and progress notes on a single date. At least one visit must have all three key components. Day-of-discharge services have unique codes and criteria. Whether the patient is considered “new” or “established” does not apply to hospital services.

The initial encounter refers to the first time a physician sees a patient, as an attending physician or as a consultant. Most often this is at the initial history and physical exam (H&P). After that, visits with the patient by the same physician or any physician in the same hospitalist group are subsequent encounters. Other E/M codes, such as critical care and prolonged services as well as additional CPT^© procedures or services, may be added to the basic E/M service if certain criteria are met.

For inpatient services, a specific order to “admit” the patient is required by Medicare regulations. Otherwise, payment for services may be denied.

In the academic setting, if teaching physicians wish to submit a claim for professional services, they may independently assess the patient, evaluate clinical data, review and annotate an intern's or resident's note, and authenticate it by signing. Of course, as an alternative, the teaching physician may perform a complete and separate H&P or progress note, but it is not a requirement.

Finally, most payors (including Medicare) no longer recognize consultation codes for inpatient services and do not pay for “comanagement” of patients—that is, two different physicians seeing and treating the patient for the same condition. Under Medicare regulations, only one clinician (usually the attending physician) will be paid for professional services on the same day if the first-listed diagnosis on claims submitted by more than one physician is the same. All physicians involved in a patient's care on the same day must communicate and agree upon the principal condition(s) for which each is billing.

Richard Pinson, MD, FACP, is a certified coding specialist and co-founder of HCQ Consulting in Houston. This content is adapted with permission from HCQ Consulting.

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Ask Dr. Pinson: Are clinical signs sufficient for coding?

Q: I am a coder and have a question related to the Coding Corner column titled “Respiratory failure in COPD patients” (ACP Hospitalist, April 2010). We had a patient present to the emergency department (ED) with exacerbation of COPD, and the respiratory failure criteria fit four of the defined respiration clinical signs. The patient was admitted with a diagnosis of acute exacerbation of COPD, noted in the inpatient chart, and was placed on bilevel positive airway pressure. The patient's stay was only one day. The final diagnosis said “acute respiratory failure secondary to exacerbation of chronic obstructive pulmonary disease.” His clinical signs were:

Oxygen saturation: 68%

Pco₂: 96 mm Hg

pH: 7.23

Po₂: 52 mm Hg

Serum bicarbonate: 40.2 mmol/L

The documentation in the ED dictation, the inpatient history and physical, and the progress notes never mentioned acute respiratory failure, even though clinical signs did. Does acute respiratory failure have to be written in the chart in order to code it, or are the clinical signs enough? Should we be querying the physicians for this documentation if they only mention it on the final discharge summary?

A: This is a very pertinent question. First of all, diagnosis coding cannot be based on clinical criteria alone. A clinician involved in the patient's care must state a diagnosis. However, if the clinical criteria are present in the medical record, it is appropriate to query the physician for clarification of the significance of findings that are not documented clearly.

The entire medical record is used for coding purposes. A diagnosis of acute respiratory failure (ARF) in the discharge summary is certainly acceptable for coding purposes if there were symptoms of ARF present and if the clinical criteria were met. Whether ARF is assigned as the principal diagnosis depends upon the circumstances of admission and the “focus” of the patient's treatment. As repeatedly stated by the official coding guidelines, it may take several days (“after study”) to establish a definitive condition that caused or is causing a patient's symptoms.

In the case described here, ARF (518.81) should certainly be assigned based on the discharge diagnosis which is consistent with the clinical signs and laboratory results. It could be the principal diagnosis depending upon the circumstances documented in the medical record. If there is any uncertainty whether ARF was present on admission, the coder should query the attending regarding present-on-admission status.

Got a documentation or coding conundrum? Dr. Pinson will respond immediately, and the question may then appear in an upcoming issue of the magazine. Please e-mail your questions.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated