Use these frequently asked questions (FAQs) to reach level 5.

A patient reports to the emergency department (ED) in such severe respiratory distress that she can’t communicate during the history of present illness (HPI) portion of the Evaluation/Management service. The patient also presents to the ED alone via ambulance, which means there was no one else to speak for her.

How can a medical coder decide on the history level for this emergency department E/M service? Knowing an important exception to the HPI rules in emergency department settings will help you report these incidents correctly.

When a doctor documents that an HPI is unobtainable due to patient condition, you can invoke the caveat, says Lori Bettencourt, CPC, PCS, coder at Pro-Medbill LLC in Hampton N.H.

Advantage: The ED caveat can put off E/M downcoding based on the E/M HPI component. Follow this frequently asked question to get the lowdown on all the ED caveat rules you will require to code correctly every time.

What’re the caveat basics?

“In real life, emergency department physicians are not always able to get a thorough and comprehensive history from a patient. The doctor should of course always document any history they can obtain from the patient, family or friends, EMS, nursing home, and the like,” says Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass. If the history is limited, but, the caveat “allows the physician to get full-credit’ for even an all-inclusive history – if you document why the history could not be obtained,” stresses Lemanski.

“The caveat is a CPT omission exclusive to emergency medicine 99285 services. It provides an exception to the Evaluation/Management content requirements when the physician is not able to acuire the required [history] information,” says Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La. This could be owing to the urgency of the patient’s condition or the mental status of the physician.

For example: The emergency department physician carries out an all-encompassing exam and high-complexity medical decision making for a patient, but she can’t get adequate information from the patient for a comprehensive history. If you invoke the emergency department caveat in this instance, you might be able to go for 99285 (Emergency department visit for the E/M of a patient, which calls for these three vital components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a complete history; a comprehensive exam; and medical decision making of high complexity…).

How about a clinical instance?

Think about this probable ED caveat scenario, courtesy of Edelberg:

A patient, aged 64, presents to the emergency department with altered mental status and left-sided facial droop. The physician examines the patient, however the patient can’t provide any useful history information. The doctor orders a CT scan of the head, the patient is admitted to rule out a stroke. Notes point to the fact that the physician performed a comprehensive exam and high MDM.

In this situation, you might be able to call upon the emergency department caveat if the doctor documented her inability to obtain a full history, and report 99285 for the encounter.

How can I identify potential caveat claims?

In an ideal world, the doctor would stamp “ED caveat” on each relevant claim, however coders will have to be good spotters in order to make the caveat work for them.

How? Coders might be able to spot caveat situations based on terms the doctors uses, Bettencourt says. Some terms that could point to a caveat if they appear in the notes cover:

– history unobtainable

– history obtained by family member owing to altered mental status.

Other possible keys: Lemanski offers these terms that might point to a patient that is not capable to fully communicate:

  • unresponsive
  • obtunded
  • comatose
  • aphasic
  • paralyzed and intubated
  • incoherent owing to intoxication or drugs.

How should I document the caveat situation?

In order to submit a successful caveat claim, however, you need to take in two specific pieces of information. Figure out what they’re by registering for the ED Coding Alert.