An interview with reimbursement and coding expert Michael Granovsky, MD, CPC, FACEP

When it comes to compensation, good documentation is a physician’s best friend.

Increasingly, emergency physicians find that anywhere from 30 to 50 percent of their compensation is based on RVU production. Some groups have even adopted 100 percent RVU-based compensation models, said Michael Granovsky, MD, CPC, FACEP, president of Logix Health, a national ED billing company. Without adequate and thorough documentation of evaluation and management (E/M) services, providers risk losing RVUs and having payments reduced for the care they provide.

It pays for physicians to take notice.

As much as 89 percent of the revenue in the ED comes from the E/M codes level 1 (92281) to level 5 (92285) and critical care.

An emergency physician would expect to be compensated less for seeing a patient with a simple bee sting than for seeing a patient with severe chest pain. However, the physician who does not adequately document the chest pain case may find it downcoded. A level 5 downcoded to a level 3 represents a loss of 64 percent of the RVUs and is roughly equivalent to providing a level 4 service for free.

The insurance companies will not see the patient’s chart, thus it is up to physicians to empower coders with adequate documentation to report the appropriate code for services provided. The number-one way to ensure this is to provide the documentation required by the Medicare 1995 documentation guidelines appropriate for the care delivered (see Table 1).

Table 1. Medicare 1995 Guidelines Typical Requirements

It’s important to note that doesn’t mean overdocumenting.

“You can’t take an ankle sprain and document it excessively, and it magically becomes a level 5,” said Dr. Granovsky. “We are seeing a significant increase in audit activity targeting the overuse of macros.”

Three primary elements factor into determining the E/M level of a case: history, physical exam, and medical decision making.

History is composed of chief complaint; history of present illness (HPI); review of systems (ROS); and past medical, family, and/or social history.

The minimum number of HPI elements for E/M levels 4 and 5 is four, and failure to meet this is the single most costly documentation error. Dr. Granovsky recommended that the rich clinical detail in the HPI become one of the tools physicians use to paint a clear clinical picture in what otherwise might be a bland electronic medical record (EMR) history and physical exam.

“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.