ED evaluation note

• Chief complaint. Chest pain, cough, fever, and "not feeling well."

• History of present illness. The patient is a 91-year-old male brought to the ED [emergency department] from the nursing home for evaluation. Apparently he was in his usual state of health the day before yesterday, but late in the day yesterday; he began to have some chest tightness, a slight cough, and a low-grade temperature in the evening.

This morning the nursing home staff reported that he was more congested and had several bouts of emesis, proceeded by nausea soon after eating. He had an elevated temperature this morning. Dr. Jones was consulted by telephone, and a CBC [complete blood count] and chest X-ray was obtained. The CBC was abnormal, with 21.0 of WBC and a differential of 63 segs, 2 bands and 1 eosinophil. She believed he may have a bronchitis or pneumonia and sent him here for further evaluation. While in the ED, he vomited twice.

• Current guidelines. Four elements are mentioned, so the History of Present Illness is considered extended (location, timing, duration, context, and associated signs and symptoms).

• New framework. The assessment would stay the same: extended HPI met by four items.

• Review of systems. Please refer to nursing assessment. Negative, except for current respiratory complaints and chronic obstructive pulmonary disease.

• Current guidelines. Complete level may be met, if the nursing assessment includes review of at least 10 systems. Since the physician has indicated the required "all others negative," this is validated.

• New framework. Positive responses and clinically relevant negatives for at least five systems are needed for complete Review of Systems (ROS). A notation such as "ROS negative" is adequate.

• Past medical history. Significant for Type II diabetes mellitus and hypertension. The patient has had COPD for the last five years and continues to smoke, whenever he can. He has no known allergies.

• Current medications. A diuretic, Dyazide, and subcutaneous insulin.

• Current guidelines. Items are included from only one history area, so the requirements for a complete Past, Family, and Social History (PFSH) are not met. PFSH is "pertinent," not "complete."

• New framework. "Complete" requires at least one item from any two of the three history areas, so in this case, it is also not met due to the omission of social and family history.

• Discussion. In the current system, three of three history requirements must be met to carry the history portion of E&M coding. Using the new framework, only two of the three categories is required to meet the requirements. Since the HPI and the ROS requirements were met, we could count this history as complete instead of detailed.

Physical examination:

• Vital signs. T 100.3, P 88, R 20, BP 116/84. Head, eyes, ears, nose, and throat is relatively unremarkable except for bilateral ptosis of the eyelids of longstanding duration. Pharynx is mildly erythemous. Neck is remarkable for slight lymphadenopathy. Chest shows increasing effort with respiration, has diffuse crackles throughout, but no rales appreciated. There are scattered wheezes, but no tenderness to palpation. Heart is sinus rhythm with no murmurs or S3. Abdomen is obese, without masses or ascites. Bowel sounds negative. Extremities: No clubbing, cyanosis, or edema in legs and feet. Neurologic examination is grossly normal. Patient is alerted and oriented to time, place, and person, and answers most questions appropriately. Mood and affect are appropriate to circumstances.

• Current guidelines. Detailed examinations require six systems to be examined with at least two elements covered and comprehensive examinations require nine or more systems be examined or a complete examination of a single system be met. In our case, seven body systems were documented, and five body areas were covered. The general multi-system exam criteria require two elements identified by "bullets" from each of nine areas/systems. Nine systems were touched on, but requirements for "two elements" were not clearly identified. The highest level of exam support is detailed.

• New framework. In this system, detailed exams require 12 to 17 items be present; and a comprehensive exam requires 18 elements. The new framework says that checklist formats are acceptable for this purpose. It says that a brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings, which eliminates the requirement to document actual elements. The draft document also contains examples of "simplified" documentation examples such as HEENT neg" [Head, Eyes, Ears, Nose and Throat neg] counts as three exam items. More comprehensible tables are provided with useful examples to outline the examination "items." In this case, we earn:

— one item for the constitutional system;
— one inspection of head;
— one examination of neck;
— one examination of eyelids;
— one examination of oropharynx;
— one inspection of chest;
— one palpation of chest;
— one auscultation of lungs;
— one auscultation of heart;
— one palpate lymph nodes in neck;
— one inspection of abdomen;
— one palpation of abdomen;
— one auscultation of abdomen;
— one examination of leg;
— one examination of feet;
— one neurologic evaluation of higher function;
— one psychiatric assessment of orientation;
— one assessment of mood and affect.

Using this system we have the 18 items required for the comprehensive examination.

Medical decision making:

• Impression. Viral bronchitis and/or pneumonia with possible influenza.

Plan. I suspect this patient likely has a viral syndrome, flu-like in nature. The main concern I have is his inability to keep anything down. I have discussed the case with Dr. Jones, and we believe he should be admitted for further observation and care. We will start him on ancef I.V., one gram every eight hours. In the meantime, I will hold his daily doses of insulin and do accuchecks after each meal and at bedtime and put him on a sliding scale. We will start D5 1/2 normal saline to run at 75 cubic cc per hour, and we will check a general profile. If electrolyte abnormalities are present, we will correct appropriately.

Current guidelines. The current system requires evaluation of the amount and complexity of the data to be considered, the number of diagnoses and treatment options, and the risk of morbidity and mortality. Using this system, we note that these are new problems to the examining physician and additional workup is needed to make a definitive diagnosis. The risk of morbidity or mortality would be considered moderate, and the amount and complexity of data are limited. Using the grid for assessment, we find that decision making is supported at the moderate level.

New framework. The new framework requires less work to arrive at the same conclusion, since three categories collapsed into one grid. Three levels are possible: low, moderate, and high complexity. Each levels has sample "number of diagnoses and/or risk of complications," "diagnostic procedures/tests ordered and/or amount of data to be obtained or reviewed," and "management options selected" listed. The level is selected from the appropriate category based on the criteria provided. In our case, we have an acute illness with systemic symptoms in a patient to be hospitalized. The data to be reviewed and obtained is expected to require at least 10 minutes of physician time.

Conclusion. Using current guidelines for Emergency Room service coding, a detailed history, detailed examination, and decision making of moderate complexity results in the selection of code 99283. Using new framework guidelines, we can validate a complete history, a comprehensive examination, and decision making of moderate complexity. This makes it possible to select 99284. In the proposed APC system, hospital prospective payment would move from APC group 953 to 955, based on the E&M code level assigned, increasing the reimbursement.

Although these draft guidelines may not be the same as required in the future, it is important for hospital-based coding professionals to begin watching the development of guidelines. This is an area hospital-based coders will need additional education and development to understand. Current systems should be fine-tuned to capture required documentation. As new systems are implemented, reimbursement is optimized, and documentation methods remain efficient and adequate for claim validation.