We find ourselves halfway through 2022 and already we’re looking forward to the end of the year to see what those 2023 documentation guideline changes will be. I am most excited to see what those changes will be as we expand 2021 documentation guidelines into other types and places of E&M services and personally, I think I’m most excited to see the expansion drift into the emergency room services specifically -as we see most discrepancies occur at the point of new problem with additional work up -this being the biggest differentiation between that 99284 and the 99285. You know, I don’t really think that most providers stand there when they see a patient and think “which carrier is this… and which carriers’ decision making do I need to understand?” I have to tell you, there are some commercials payors that have policies that do teeter differently when it comes to the interpretation of additional work up. Now, a lot of the Medicare MACS have good interpretations as to how they differ when it comes to additional work up, and a lot of those policies have even said their interpretation of additional work up applied to all places of service, whether it was the emergency room or not. However, as we’ve seen 2021 documentation guidelines emerge, we have seen those MACS retract a lot of those statements from their website. What’s difficult about that is we’re still using 1995 and 1997 documentation guidelines. But remember, new problem with additional work up is actually not 95 and 97 documentation guidelines. That’s actually Marshfield guidelines and unfortunately, Marshfield guidelines is a scoring tool, not documentation guidelines. But it has become the industry standard, and it has become how a lot of payor recommendations and payor scoring processes take place. So, until we have implementation at the beginning of 2023, we are left using additional work up. So, what I recommend is, that until the end of the year, your organization have a policy on how you interpret additional work up, if you don’t already. (I know, I bet you think you can’t see anything from me without me saying “you should have a policy”…maybe that’s what we should call this “You should have a policy series” – hahaha!) But anyway, you should have a policy– and your policy should address how your organization is going to view what is additional work up in the emergency room. Again, keeping in mind whether your MAC previously stated that the emergency room is the same as all other places of service, as most MACS did.
So, what is additional work up? Is additional work up only admission when we’re talking about the emergency room? Everything that’s done in the emergency room is hands-on. If the provider does a diagnostic, results are available immediately. If advanced imaging is needed, the results are available immediately. There really isn’t much that’s done in the emergency room that is “additional work up”, except admission. So, for a lot of auditors, coders (and carriers), additional work up hasn’t ever been much beyond admission. However, let’s step outside of that box for just a moment. What if there is a patient that goes into the ER and they are high risk, they do have imminent threat, but during the encounter within the emergency room that imminent threat has subsided. They are ready to discharge the patient, but there is high risk that imminent threat will reoccur and we need them to have additional work up within the very near future -say within the next 24 to 48 hours- with a specialist. Guys, I’m not talking about the patient has a fracture and they need to go see an orthopedist. I’m talking about a patient who maybe had a seizure, and they need to go see a neurologist to ensure that they are put on long-acting medications so seizures don’t reoccur. They need to find out the source of those seizures to ensure adequate therapy. That’s what I’m talking about here. That is, additional work up, is it not? So, high risk can occur with discharge. If we talked to our clinicians in the emergency room, we as coders and auditors often feel that high risk with imminent threat shouldn’t be walking out of the emergency room. But our ER providers will often tell us that does occur. So, if that does occur, we need them to portray that in the documentation… that eminent threat did occur with that patient who was brought to a stable state enough that the patient could be discharged. But the next step to get the five, because that’s a four, is what is the additional work up? A 99284 is a new problem in the ED for that top part of your MDM scoring. But to get the 99285, there has to be additional work up that is beyond today’s encounter. So, what is that additional work up? A lot of times in that example that I gave of the patient with the seizures, the emergency room provider fails to communicate that. They’ll just document something to the effect of the patient should follow up with a neurologist, or the patient is told to make an appointment with a neurologist, or we will schedule the page patient with the neurologist. But it’s not documented to show that complexity of this additional work up is needed because the patient has high imminent risk if they don’t. We need that contextual risk documented by the emergency room physician to communicate the high risk that is needed to contextualize the additional work up required. Make yourself a policy. Make yourself a team to follow-up and maybe score some of these together to ensure that you collectively are understanding what you’re looking at and that these are high risk imminent threat with actual additional work up outside of admission. I hope this is helpful information for you and I can’t wait till 2023 changes!
If you have any questions, I’m always around! Comment. Feedback. E-mail. I’m always happy to help you review any of these and give my feedback. In the meantime, I invite you to check out this brand-new NAMAS resource especially developed and packaged for ED services… ED Service: Packaging up the Audit. and you can watch the video on ED Services on the NAMAS YouTube channel.