Discussion Unit 2 FAQs Advanced Coding

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Feb 20, 2024

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Unit 2 Discussion Hospital Outpatient Emergency Room Coding 1.) Q. Clarification was needed of when a physician and a physician assistant or nurse practitioner share an E/M service and if the physician must document the level of medical decision making for the physician assistant or the nurse practitioner, or if the attestation indicates the elements of the E/M service each provided to support reporting a shared E/M service? A. The physician may evaluate the physician assistant or nurse practitioners’ documentation and clearly state the management plan and take responsibility for the patient. However, If the E/M code requires a category 2 assessment of an independent historian or category 3, discussion of management or test interpretation, then the physician should include this in his or her own documentation of their own interpretation and the discussions that they had with any external physicians, or an independent historian. If the physician performed and documented MDM elements that did not require a category 2 or 3 during the patient encounter, they are not required to additionally document an attestation, they can just approve the physician assistant or nurse practitioners’ documentation. According to American Medical Association, (2023), medical decision making (MDM), includes establishing diagnosis, assessing the condition, and selecting a management option. This includes the number and complexity of problems that are addressed at the time of the encounter, the amount of data to be analyzed and the risk of complications and/or morbidity of patient management (American Medical Association, 2023 p.8). This FAQ made me realize that if a physician is working closely with a physician assistant, and if the encounter requires a category 2 independent historian or category 3 discussion of management or test interpretation with other external physicians than the physician had his or her own discussion about treatment, then the physician should document his or her conversations in the medical record. This would be applied in coding and E/M service, and understanding the documentation needed for category 2 independent historian and category 3 discussion of management or test interpretation with an external physician, reflecting the level of MDM for the appropriate E/M code. 2.) Q. What documentation is required for a physician to report a category 3 level of MDM? A. The documentation should support that the physician had contact and discussion whether in person, phone call, text message or secure electronic message with an external physician that was involved with the care of the patient. The documentation from the physician will explain the contact with the external physician and this would determine the category 3 for the level of MDM for the E/M code. According to American Medical Association, (2023), the amount and complexity of the data to be reviewed could include test, documents, orders, or independent historians, independent interpretations of test, and the discussion and management or test interpretation with an external physician.
This FAQ inquiring about physicians reporting a category 3 level of MDM means that if a physician documents that he or she had a discussion with an external physician about the patient being treated, this would be considered a category 3 level of MDM for an E/M code. This would be applied in coding for an E/M service and helpful in deciding the level of MDM and what is considered a category 3 discussion of management or test interpretation for the appropriate E/M code. 3.) Q. What is an independent historian? A. An independent historian can be emergency medical technicians, guardian, caregiver, spouse, or witness. These individuals can provide the physician with the patient’s history, in addition to the patient or if the patient is unable to provide a history his or herself. If the patient is not of legal age, the independent historian can provide all medical necessary information and is most likely the legal guardian or parent. This FAQ is good to know when the physician must gather medial history from another person other than the patient or together with the patient. This would be documented that the physician also gathered medical history from another person. This would be applied while coding the E/M service, and the documentation necessary to include a category 2 independent historian and the of the level of MDM for the appropriate E/M code. According to Ejak (2020), some examples of independent historians could be a pediatric patient, an elderly patient with dementia, a mental health patient, a trauma patient or acute injury patient who can not provide a full medical history. This discussion post about Emergency Room coding questions made me realize that time is not a factor in selecting the correct emergency department E/M code. According to American Medical Association (2023), emergency room services are provided on a variable intensity basis, involving multiple encounters with different patients. It would be extremely hard for an emergency room physician to constantly document the time spent with a patient who presides in the emergency room. It is however, based off MDM straightforward, low, moderate, and high. It is important that you understand how to correctly use the levels of medical decision-making chart and understand all the elements included in selecting the correct E/M code. Reference: The American College of Emergency Physicians. (2023). 2023 emergency department evaluation and management guidelines. American College of Emergency Physicians. https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines- faqs/ American Medical Association. (2023). CPT 2024 professional edition (4th ed.) Ejak, C. (2020 ) Focus on e/m services: independent historian . Inside Angle From 3M Health Information Systems. https://insideangle.3m.com/his/blog-post/focus-on-e-m-services-independent-historian/
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