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Additional information on a variety of topics and frequently asked questions about Emergency Department documentation requirements. (Click on any topic to scroll to that topic)

Interpretations

Separately Billed Interpretations

ED Physicians and APCs are permitted to separately bill for interpretation of tests. The most common examples of independent interpretation of tests in emergency department are:

EKG
X-ray
Point of Care Ultrasound

Specific criteria must be met and documented to separately bill for the interpretative services, including"

A “billable interpretation” is different than a “review” of the image.
- A complete interpretation must be completed and documents to separately bill.
- If a complete interpretation is not completed (only visualizing or reviewing a diagnostic test), the work is incorporated into the level of complexity of data in the MDM scoring.
For a complete interpretation for billing purposes:
- The written report should be similar to what a specialist in the field would prepare.
- A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.

If the CPT code for the independent interpretation is separately reported, it cannot also be counted in Data Category 2 when determining MDM.

EKG Interpretation

The documentation for EKG’s personally interpreted by an emergency physician must:

Contain an interpretation of the EKG
Not be just a review of the findings

Although a separate document is not necessary, there must be a formal written report in the physician’s dictated or written notes. The report:

Must meet the hospital’s requirement for an official EKG interpretation
Should address or answer any pertinent clinical issues that prompted the request for the EKG

EKG’s that are electronically read must be:

Over-read
Corrected (if necessary)
Signed
Notation made on the chart either agreeing with or modifying the computerized reading

EKG interpretations should include at least 3 specific parameters, such as:

Rate
Rhythm
Axis interval
QRST wave comments
Acute or chronic changes
Comparison with the most recent tracing
Clinical findings and/or diagnosis

While every single parameter is not required for each tracing, the appropriate measurements must be identified to communicate the significance of the EKG. Simply stating “EKG-normal or negative” is not sufficient!

Examples of EKG Interpretations

EKG: Sinus tachycardia, rate 108; non-specific ST-T changes; no acute ischemia noted; no EKG available for comparison

EKG: Sinus bradycardia; rate 56; left axis deviation; no significant changes when compared with prior EKG

EKG: Reveals the patient to be in normal sinus rhythm with a rate of 66; PR and QRS intervals within normal limits. There are some QRS complexes in lead III and T-wave abnormalities in I, but when compared to a prior EKG, there are no acute changes noted.

EKG

X-ray Interpretation

X-ray

The documentation for X-rays personally interpreted by an emergency physician must:

Contain an interpretation of the X-ray
Not be just a review of the findings

Although a separate document is not necessary, there must be a formal written report in the physician’s dictated or written notes.

The report:

Must meet the hospital’s requirement for an official X-Ray interpretation
Should address or answer any pertinent clinical issues that prompted the request for the X-ray

X-ray interpretations should include comments on specific parameters, such as:

Detailed description of X-ray findings
Specific location of imaged organ
Number of views
Quality of study
Pertinent findings, both positive and negative
Recommendations for further studies or treatment
Clinical impression or diagnosis

While every single parameter is not required for each image, the appropriate information must be identified to report the significance of the x-ray(s). Simply stating “x-ray negative for fracture” is not sufficient.

The following is recommended minimum number of documented pertinent findings:

At least 2 findings for areas such as the ankle and wrist
At least 3 findings for areas such as the chest and abdomen

Examples of X-ray Interpretations

X-ray: PA and Lateral Chest, 2 views: negative for infiltrate with no cardiomegaly or masses noted

X-ray: AP and Upright Abdomen, 2 views: bowel gas pattern - no ileus, obstruction, air-fluid levels or free air; no other abnormalities noted

X-ray: Right Thumb, 3 views: fracture distal tuft with soft tissue swelling, no foreign body noted, no other bony deformities noted

POCUS

Point of Care Ultrasound Interpretation

Coming Soon

Fracture Care

Critical Care

Fracture Care

There are two types of fracture care provided in the ED.

Definitive (Non-Manipulative) Care

Fracture care codes may be billed even though care may not include manipulation.

The fracture does not require manipulation
The fracture is stabilized by immobilization
- This would be an application of ice, tape, or splinting
- Examples: fingers, toes
The patient could be provided pain management

Restorative (Manipulative) Care

Displaced fractures are treated with manipulation to restore the bone to the correct anatomical position.

This would include traction, flexion, and/or extension, and medial lateral rotation to restore the displaced bony fragments to their original positions
The fracture is immobilized by using a cast or splint
Splinting / strapping is included in the fracture care code and may not be reported separately.

4 Critical Items to Document

To ensure proper coding, document the following elements in all Facture Care encounters:

Specific fracture diagnosis
- Laterality
- Type (open, closed, pathologic, displaced)
- Location (distal, head, shaft, proximal)
- Pattern (transverse, oblique, segmental)
- Examples: Non-displaced closed fracture of the distal phalanx of right great toe
Procedure note indicating treatment without manipulation, manipulation or reduction of the fracture and who performed it;
Specific follow up / referral time (i.e., in 1-2 days or in 5-7 days)
Notation if an orthopedist was called to care for the patient in the ED

Billable v Non-Billable Fracture Care Services

Additional Fracture Care Documentation Considerations

E/M services may be billed in addition to fracture care (H&P, MDM must be documented)
Any other procedure performed (not splinting/strapping) during the same encounter, including X-rays may be billed
Multiple fracture care codes for the same site may not be billed.
Attempted reduction that is not successful is reported with appropriate fracture or dislocation CPT code as a reduced service using a 52 modifier.

Critical Care

A critical illness or injury

Acutely impairs one or more vital organ systems
Creates a high probability of imminent or life-threatening deterioration in the patient’s condition

Critical care services are billed based on the time spent providing direct critical care services

Clinical Condition Criterion

The high probability of sudden, clinically significant deterioration in the patient’s condition required the highest level of preparedness to intervene urgently.

Conditions requiring critical care services to treat or prevent clinically significant deterioration could include:

Respiratory failure
Renal failure
Circulatory failure
CNS failure
Metabolic failure
Multi-organ failure
Severe shock
Overwhelming infection
Psychiatric decompensation

Treatment Criterion

Critical care services require direct personal management by the physician.

They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician.
Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration in the patient’s condition.

Possible indicators of aggressive management include:

Anti-arrhythmics
Nitroglycerin / nipride drips
Thrombolytics
Dopamine
Intubation
Cardioversion / defibrillation

Physician Time in Critical Care Services

The physician’s documentation must identify the total time critical care services were provided and the time spent performing separate procedures was subtracted from the total time

The total time should represent the time the physician was personally engaged in work directly related to the patient’s care, whether at the bedside or elsewhere in the ED
Time spent performing separately billable procedures cannot be counted as critical care time.
Time spent by residents under the physician's supervision cannot be counted as critical care time.
Example: Total critical care time was 45 minutes excluding separately billable procedures.

The following services are included in critical care:

Discussions with ancillary staff
Reviewing monitor data, nursing notes and old charts
Documentation time
Consultant collaboration on finding and treatment options
Medications orders and management
Care, transfer of care and discharge plans
Re-evaluations
Ordering and reviewing tests
Time involved obtaining additional history or discussing treatment options if a patient is unable or incompetent to make treatment decisions
- Does not include time spent comforting the family or discussing the patient’s status
- The necessity and the source (family, EMS, nursing home, private physician, other surrogate decision makers) of the discussions should be documented

Separately billable procedures may include:

Intubation
Central line
Arterial line
Chest tube
CPR
EKG Interpretations

"Same Practice" Billing

Critical care can be billed on the same date by the same clinician/group if the physician documents that the E/M service is provided prior to the critical care service at a time when the patient did not require critical care.

If both a physician and APC provide critical care services and are employed by the same group and reported under the same TIN the total time is summed and the clinician who furnishes the “substantive portion” (more than half) of the cumulative critical care time will report the critical care services.

Shared Visit

A shared (or split) visit is an E/M service

Is performed in part by both a physician and a non-physician practitioner (NPP) who are in the same group
Could be billed by either the physician or NPP if furnished independently by only one of them

For all shared visits, one of the practitioners must have face-to-face (in-person)
contact with the patient, but it does not necessarily have to be the physician, nor the
practitioner who performs the substantive portion and bills for the visit. The substantive
portion can be entirely with or without direct patient contact and is determined by the
proportion of total time, not whether the time involves patient contact.

Payment is made to the practitioner who performs the substantive portion of the

visit.

Substantive Portion

For E/M services, substantive portion is defined as:

More than one half (1/2) of the total time spent performing the shared visit by the physician and NPP, or
One (1) of the 3 key components of the E/M: history (Hx), Exam (Ex) or medical decision making (MDM).
- When one of the three key components is used as the substantive portion, the practitioner who bills the visit must perform that component in its entirety.

For Critical Cares services, substantive portion only means more than one half (1/2) of the total time spent performing the shared visit by the physician and NPP.

Qualifying Time

Except for critical care visits (see Critical Care section), the following listing of activities can be counted toward total time when performed and whether or not the activities involve direct patient contact:

Preparing to see the patient (for example, review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically appropriate examination and/or evaluation
Counseling and educating the patient/family/caregiver
Ordering medications, tests, or procedures
Referring and communicating with other health care professionals (when not separately reported)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
Care coordination (not separately reported)

Practitioners cannot count time spent on the following:

The performance of other services that are reported separately
Travel
Teaching that is general and not limited to discussion that is required for the management of a specific patient

Distinct Time

Only distinct time can be counted. When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted.

Example: If the NPP first spent 10 minutes with the patient and the physician then spent
another 15 minutes, their individual time spent would be summed to equal a total of 25
minutes. The physician would bill for this visit, since they spent more than half of the total
time (15 of 25 total minutes). If, in the same situation, the physician and NPP met together
for five additional minutes (beyond the 25 minutes) to discuss the patient’s treatment plan,
that overlapping time could only be counted once for purposes of establishing total time and
who provided the substantive portion of the visit. The total time would be 30 minutes, and the
physician would bill for the visit, since they spent more than half of the total time (20 of 30
total minutes).

Documentation Requirements

The medical record must

Identify the physician and the NPP who performed the services
The individual who performed the substantive portion of the visit and bills for it must sign and date the medical record

If the physician provides more than one half of the total time performing the shared visit, then he/she must document a statement to that affect:

Example: "I provided a substantive portion of the care of this patient. I personally provided more than half of the total time dedicated to treatment of this patient."

If the physician performs the substantive portion of the visit by completing one of the 3 key components, then he / she must document a statement to that effect.

Example: “I personally performed the entirety of the physical exam for this patient.”

Documentation by Others

Members of the care team (APCs, residents, nurses, students) may document the details of the key component for the services performed by the physician. The reporting physician must review and verify notes made by others for the services the reporting physicians provides and bills. The physician must document a statement to that affect:

Examples of acceptable attestations:

"I provided a substantive portion of the care of this patient. I personally performed the entirety of the (Insert: History or Exam or Medical Decision Making) for this encounter."
"I personally saw and evaluated the patient. I discussed the management with the APC and reviewed the APC's note and agree with the documentation. I performed the substantive portion of the (Insert: History, Exam or Medical Decision Making) as documented by the APC."

Advanced Care Planning

Advance Care Planning (ACP) involves the explanation, discussion and documentation of advanced care directives between an ED physician and a patient and records the wishes of the patient pertaining to his/her medical treatment at a future time should he/she lack the ability to make the decision at that time.

Medicare provides no specific requirements for using ACP codes, other than it must be a voluntary face-to-face discussion regarding ACP with patient, proxy or surrogate.

ACP Billing

ACP services performed by a physician:

Can be billed with E/M services
Can be billed with Observation services
Can not be billed with Critical Care services

ACP services are reported on a time basis (the length of time is equal to one minute past the midway point of the code interval) utilizing the following CPT codes:

99497

Initial 30 minutes (must be at least 16 minutes)

99498

Each additional 30 minutes (may be billed as many times as needed to cover the time spent; must be at least 16 minutes for each additional unit)

ACP Documentation

Advance Care Planning documentation must include:

Persons present and involved in the discussion, including the patient, family/friend, hospital staff, etc.
Amount of time spent providing the service
Sufficient detail to reflect and justify the length and complexity of the discussion

Advance Care Planning documentation may include:

Discussion of goals and preferences for care
Complex medical decision-making regarding life-threatening or life-limiting illness
Explanation of relevant advance directives, including (but NOT requiring) completion of advance directives
Engaging patients, family members and/or surrogate decision makers, as clinical situation requires
Documents completed, if any (such as DNR, Living Will, MOLST)
Decision made, if any (code status, DNR, CPR/life sustaining measures, hospice)
Prognosis
Palliative and disease-directed care options
Options for avoiding or limiting aggressive care
Choosing and utilizing surrogate decision makers

ACP

Smoking Cessation

Smoking cessation counseling services are time-based codes.

The documentation of these services must include the amount of time spent with the patient.
Smoking cessation counseling services may be provided on the same day as an E&M service or a wellness visit (for Medicare patients) but the time of the smoking cessation counseling must be distinct from the other E&M service.
For other time-based EM services provided at the same session, the time for each separate service must be clearly documented.

Smoking Cessation Counseling Billing

Smoking cessation services are reported utilizing the following CPT codes:

99406 - 3 to 10 minutes
99407 - Greater than 10 minutes

In addition to the ICD-10 code for tobacco use (F17.2xx series), diagnosis code(s) are reported that describe the adverse effects the patient may be experiencing from tobacco use at the time of the visit, such as atherosclerosis or chronic obstructive bronchitis.

Frequency

CMS will allow two individual counseling attempts per year.
Each attempt may include a maximum of 4 intermediate OR intensive sessions (total benefit covering up to 8 sessions per year).
The practitioner and patient have the flexibility to choose between intermediate or intensive cessation counseling sessions for each attempt.
Commercial payors may have additional criteria listed in their Behavior Health or Preventative Medicine Policy Guidelines.

Coverage Conditions

The individual uses tobacco, regardless of whether there are signs or symptoms of tobacco-related disease.
The services are furnished by a qualified health care provider.

Documentation Requirements

In addition to documenting that the coverage conditions were met, documentation must include verification of the counseling intervention. Documentation must demonstrate the patient was:

Asked about tobacco use
Advised to quit
Assessed for the willingness to attempt to quit
Assisted with the attempt to quit
Follow-up with the patient was arranged

Example:
The majority of Mrs. Smith’s 35 minute face-to-face encounter was spent reviewing her recent ultrasound and angiography studies revealing significant bilateral lower extremity PAD. We discussed the possibility of revascularization in the near future and thoroughly reviewed the risks and benefits of this procedure. She and her husband have voiced concerns and want to revisit this option in 3 months if her symptoms continue.

I spent an additional 15 minutes encouraging smoking cessation with her explaining the effects of smoking with her PAD. She currently reports smoking filtered cigarettes, approx. 1 ppd with a 25 year history. She voiced a willingness to quit and would like to try Chantix or Nicotine patches if she is unable to stop smoking on her own. Will revisit this when she returns in 3 months and prescribe one of these at that time if she is still smoking. Patient provided with pamphlet re smoking cessation.