“So when a patient comes back to the ED or is admitted upstairs or evaluated by a third party, there are robust clinical details,” he said.

Case-specific detail is what really makes a patient come to life, Dr. Granovsky said. It also demonstrates the high quality of care and offers stronger medical-legal protection.

Level 4 E/M cases must include at least two of the possible 14 ROS elements. At least 10 must be documented for a level 5. Many EMRs have large macros; be sure to add in pertinent positive and negative systems.

Table 2. 2014 ED RVUs

At least one past medical, family, or social history element must be documented for a level 4, and two are required for a level 5. Don’t forget the history caveat applies if a patient’s history cannot be obtained; however, the circumstances that prevented it should be documented.

There are 12 organ systems available under the physical exam, and eight are required for a level 5. If a patient is too ill for a full history and physical, the acuity caveat may be invoked by documenting the conditions that prevented obtaining a complete history and exam. The caveat is specific to the 99285 code and appears right in the CPT definition.

Too often, physicians miss the documentation mark. For instance, consider this chart: A 49-year-old male presents with left-sided chest pain for two hours’ duration; he reports nausea but no vomiting. He had a full physical two years ago, and he was seen by his primary physician last week, had a normal exam, had lab work, and was told that his blood pressure is high.

All of the appropriate clinical information is there, but the case would be downcoded from a potential level 5 because there are only three HPI elements, causing the provider to loose a majority of the RVUs.

Appropriate documentation shouldn’t be an overwhelming task once physicians learn the rules and work toward efficiency, Dr. Granovsky said. The ACEP website, www.ACEP.org, also contains a robust set of frequently asked questions, and ACEP hosts a five-day reimbursement course for interested physicians.

Kelly April Tyrrell is a freelance journalist based in Wilmington, Del.