Medicare Guidelines for Accurate ED Medical Coding


Most of us in emergency medicine particularly those of us that have had a chance to play with both the '95 and the '97 versions find that '95 is much more beneficial to emergency medicine. Ninety-seven medical coding guidelines just really don't fit our specialty very well.

But in saying that, actually some of the Medicare auditors are kind of doing their own twist on the '95 guidelines. And it will be important for you to know what version of the guidelines or what type of audit tools your Medicare is using if you can get, you know, if you can get a hold of that. And many times they'll publish it on their websites or in their monthly communications or monthly newsletters, et cetera. But it's helpful for you to know what version they're following.

If you have a payer that tells you they're following CPT, you might want to ask a little further and try to get them to give you some type of objective guidance to how they follow CPT. There aren't any changes per se in the E/M medical coding guidelines but what we're seeing is a tremendous shift in the industry by payers who kind of used their own version of the '95 or who looked at the CPT E/M guidelines with a different eye.

You know, for example in the CPT medical coding guidelines, duration is not included as an HPI element but it is in the 1995 guidelines. So, if you have a record that you're, you know, running really close to that for more and you have duration and someone's not going to count it, you may not make that Level V HPI, Level IV HPI, review of systems.

You know, the CPT book says all other systems for Level V - and there I believe are 14 of them. But the Medicare guidelines pretty much give us a little bit more leeway there. So, you have to be careful about that. On the physical exam constitution, it is not listed in CPT but it is in the '95 medical coding guidelines.

And then under the past medical, family, social, CPT says a complete which means three of three and the Medicare guidelines give you two of the three. So, these are things for you to be aware of. And your payers may do something very different. Your payers may have a very different spin on this.

With regard to procedures for CPT, there weren't many medical coding and billing changes that are going to impact on emergency medicine. For the most part, there was some wording changes to the burn codes, 11001, 11201 added or part thereof. So that tells us that for - in terms of lesions or body service, it gives us a little bit more leeway, that the repair codes, 12031, 12041, 12051 are intermediate repair codes.

The words “layer closure” were taken out of the actual code descriptors because it tells us up in the actual introduction that the intermediates can be single layer but with growth contamination, et cetera, et cetera. So, don't get too nervous when you see that.

You can have an intermediate laceration repair to the single layer but there it has to be fairly complex and that you're maybe debriding or there's some growth contamination requiring some extensive cleansing, et cetera. And you want your dictation or your notes from the physicians to indicate that before you use those codes. But that's something you just want to make a note of.

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