DRG Coding Advisor: ED code changes need more detailed documentation
HIM professional designs new ED form
APC codes for the emergency department (ED) have some considerable changes that went into effect April 1, and coders may miss some crucial codes without very detailed documentation on the ED medical record.
At the very least, coders and HIM professionals will need to educate ED nurses and physicians about the changes, says Molly Barksdale, RHIT, supervisor of medical records and trauma abstractor for Bay Area Hospital in Coos Bay, OR.
But an even better strategy is to change the ED medical record to reflect some of the more detailed information that is needed under the new APC codes, she adds. (To see a sample emergency department medical record supplement, click here.)
Barksdale created a new ED medical record form with the goal of capturing more of the crucial data and to improve nursing documentation, she says.
Aiming for correct reimbursement
The initial goal was to make certain documentation reflected appropriate resource utilization and coordination of services to capture the correct reimbursement, Barksdale says.
"So we compared the APC guidelines with our existing ED chargemaster and nursing documentation and focused on areas that would reflect the appropriate utilization of resources for the patient care," she explains. "We looked at it by categories, including the documentation at the triage level, nursing assessment, and coordination of care with other departments."
Pain management documentation was an important issue because of recent accreditation and Medicare guideline changes, Barksdale adds.
While creating the revised medical record form, Barksdale sought input from everyone who would be involved, including all ED nurses and physicians.
"The form evolved over a number of months with some brainstorming, working on it, and tweaking it," Barksdale says. "Then we obtained a consensus on the changes from the doctors and nurses."
Barksdale worked closely with a nurse manager, a unit secretary, the ED quality assurance nurse, and the ED medical director.
Form results from consensus of ED staff
"I was determined that the final form would be the result of a consensus, because if the ED staff is not going to use the new form to its APC reimbursement potential, then why change the form?" Barksdale says. "Also, this was a way of reaching out to them so they could have a say-so in the form and have ownership in what needs to be documented and how to document," she explains.
After several months, Barksdale had a final version that was sent to everyone involved for approval. The revised ED medical record has two pages plus a third page of discharge instructions that were written by the medical director.
Among the major changes was a process for documenting any increases in the level of care. For example, there is a box for the nursing staff to mark if the patient required psychosocial intervention, Barksdale says.
Other "yes" or "no" check-boxes will answer these questions:
- Was there a forensic exam?
- Was there domestic violence?
- Was there treatment prior to arrival?
- Was the documentation on wound care complete?
"These boxes are triggers for clinicians to do a long-hand documentation of the nursing intervention," Barksdale explains. "The first page has triggers that are primarily geared toward initial triage documentation and physician documentation, and the second page is primarily for nursing documentation."
On the second page, there are boxes and sections that detail wound care, nasogastric size, stool, Foley size, urine output, vital signs that include pain, and various fluid intakes.
Anecdotal evidence since the form was put into place with the past six months has shown that it has improved documentation and reduced coders’ calls to ED clinicians to clarify items, Barksdale notes.
Enter changes into chargemaster
Some of the recent changes to APC codes include new codes that will change how some ED services are documented and which could be overlooked if coders are not cautious, advises Phoebe Bennett, RHIA, director of special services and director of medical records at Bay Area Hospital.
"If you don’t put these new codes on the chargemaster then you’ll either have invalid ED codes or you’re going to miss that reimbursement," Bennett says. "So after April 1, the changes in the emergency room APCs are what everybody needs to be reviewing."
Here are some of the changes:
- CPT 99289: Physician constant attention of a critically ill patient during an interfacility transport, first 30-74 minutes;
- CPT 99290: An add-on code to 99289 for each additional 30 minutes of time.
"These are codes for when a physician transports a critically ill patient from one facility to another, and you can’t put it on as a facility charge — it has to be a physician charge," Bennett says.
Those two new codes should not be confused with the following two codes, which are no longer used during patient transport:
- CPT 99291: Critical care, evaluation management of critically ill or critically injured patients, first 30-74 minutes;
- CPT 99292: An add-on code to 99291 for each additional 30 minutes of time.
There also are several new codes for multiple muscle group injections for trigger points. Here are three new ones:
- CPT 20551: Tendon origin insertion;
- CPT 20552: Single or multiple trigger points, one or two muscle groups;
- CPT 20553: Single or multiple trigger points, three or more muscle groups.
For facilities, these two new immunization administration codes need to be used because intranasal oral routes have been eliminated from APC 90471:
- CPT 90473: Immunization, administration by intranasal or oral route, one vaccine;
- CPT 90474: An add-on for 90473 of each additional vaccine.
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