Angela Finnigan (angela.finnigan@ankura.com) is a Director at Ankura Consulting Group LLC in Amelia, OH; Marcella Jauregui (marcella.jauregui@ankura.com) is Director, Healthcare Risk, Privacy, Forensics and Compliance, at Ankura Consulting Group in San Francisco, CA; and Carla Starks (carla.starks@ankura.com) is Director, Healthcare Compliance, at Ankura Consulting Group in Chicago, IL.
The U.S. Department of Health & Human Services Office of Inspector General (OIG) conducts audits every year to ensure proper federal healthcare program payments are made. OIG remains at the forefront of the nation’s efforts to fight fraud in federal healthcare programs and hold wrongdoers accountable for fraud, waste, and abuse.[1] The audits are conducted based on risk areas identified by the OIG, which are put into a work plan. OIG has released its work plan for fiscal year 2022, which includes an audit of Medicare emergency department (ED) evaluation and management (E/M) services. In fiscal year 2020, OIG audits identified $566 million in expected recoveries and $920 million in potential savings for the Department of Health & Human Services programs.[2]
Performing audits that parallel the OIG work plan is imperative for healthcare organizations, as audits will identify areas of potential risks, avoid potential legal trouble or federal fines for noncompliance, and help promote the integrity of the organization’s compliance program. OIG repeatedly emphasizes in its guidance documents the importance of auditing and monitoring activities for an effective healthcare compliance program.
Routine audits should be conducted at least once annually, according to the OIG Hospital Guidance (and, of course, for-cause audits should be conducted as concerns are identified). A common method of assessing compliance program effectiveness is measuring various outcomes indicators (e.g., billing and coding error rates, identified overpayments, and audit results). Hence, organizations should develop detailed annual audit plans tailored to reduce risks associated with improper claims and billing practices.[3]
Coding for physician and NPP services in an ED setting
When coding for services in an ED setting, physicians, nonphysician practitioners (NPPs), and facilities use the same codes to report E/M services. Surgical procedures or other services performed in the ED setting are also to be reported. The codes used to report E/M services in the ED setting are 99281–99285. Criteria for determining the correct level of service, however, differs between the two providers. This article discusses the criteria for professional fee billing for services provided in the ED setting.
General principles of E/M documentation
Physicians and other NPPs are responsible for accurately, completely, and legibly documenting all services performed. Regardless of the type of services (medical and surgical) and the place of service, these principles apply:
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The medical record should be complete and legible.
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Documentation for each encounter should include:
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Reason for the encounter, relevant history, physical exam findings, and prior diagnostic test results;
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Assessment, clinical impression, or diagnosis;
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Medical plan of care;
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Date and identity of the observer; and
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The rationale for ordering diagnostic and other ancillary services (if not documented, it should be easily inferred).
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Past and present diagnoses should be accessible to the treating and/or consulting physician.
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Appropriate health risk factors should be identified.
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The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.
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The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record.
Documentation requirements for E/M services
There are several factors to consider when selecting a code for professional services: the patient type (new vs. established), setting of service (office or other outpatient setting, hospital inpatient, emergency department, or nursing facility), and the level of service performed. There are three key components to consider when selecting the appropriate level of E/M service: history, examination, and medical decision-making. For encounters that are dominated by counseling and/or coordination of care, time is the key or controlling factor used to determine a level of service.[4]
ED E/M codes 99281–99285
The ED E/M code set comprises five levels of service based on the nature of the presenting problem. There are four components to be considered when a physician/NPP chooses a level of service: the amount of history obtained, the physical exam performed, diagnostic testing required, and the complexity of medical decision-making. In the ED, there is no distinction made between a new patient and an established patient service. Additionally, the ED code set does not have typical times assigned as E/M services in other settings (e.g., office, outpatient clinics, inpatient settings). When diagnostic medical, surgical, and/or therapeutic procedures are performed in the ED setting, physicians/NPPs are instructed to append modifier -25 to the E/M service to alert a payer that a significant and separately identifiable E/M service has also been provided. Commonly performed procedures in the ED include, but are not limited to, laceration repair, intubation, insertion of central lines, lumbar punctures, and paracentesis, along with fracture care and other orthopedic procedures. These services, of course, should be properly documented in the medical record in addition to the E/M service.
Documentation requirements for ED codes 99281–99285
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99281: Requires documentation of the following three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making. Counseling and/or coordination of care with other physicians, qualified healthcare professionals, or agencies needs to be consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
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99282: Requires documentation of the following three key components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity. Counseling and/or coordination of care with other physicians, qualified healthcare professionals, or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
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99283: Requires documentation of the following three key components: an expanded problem-focused history, expanded problem-focused examination, and medical decision-making of moderate complexity. Counseling and/or coordination of care with other physicians, qualified healthcare professionals, or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
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99284: Requires documentation of the following three key components: a detailed history, a detailed examination, and medical decision-making of moderate complexity. Counseling and/or coordination of care with other physicians, qualified healthcare professionals, or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
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99285: Requires documentation of the following three key components: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. Counseling and/or coordination of care with other physicians, qualified healthcare professionals, or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
