In Emergency Medicine, complex patient problems can seem routine and even mundane to physicians and advanced practice providers.
Myocardial infarction, respiratory failure, septic shock, GI bleed, shoulder dislocations – we often think “no problem”. “Been there, done that.”
While this can be very beneficial in regards to our ability to practice medicine, it can also be detrimental to the way we approach our charting.
As providers, all too often, we have become comfortably “numb” to the value of our work.
Realize Your Perception May Not Always Be Reality.
Many of the “lower level” acuity cases which we as physicians perceive are in fact “higher level” acuity cases in regards to CPT code reimbursement.
Many perceived “level 3” cases (CPT 99283) are in fact level 4s (99284) and 5s (99285).
Recall that these CPT codes still serve as a primary avenue for establishing value in Emergency Medicine.
Our charting is now more important than ever to highlight the medical necessity, detail the severity of illness, and demonstrate the value of our care.
Regardless of the pace of our heart rates during our shifts, it is essential that we should not be dismissive when approaching our documentation.
We should all be sure to include the appropriate details of the care we have provided.
Consider this example:
An 18 year old female presents with a complaint of severe sore throat for the past 3 days. She reports multiple episodes of vomiting and some associated abdominal pain as well as some sensation of heart racing. She denies having any significant past medical history.
Physical exam reveals the patient to be well developed though mucous membranes appear dry. BP 94/54, HR 120s, RR 20, Fever 100.6 , Pulse ox 98% RA. Moderate bilateral tonsillar hypertrophy with diffuse exudates, bilateral tender cervical lymphadenopathy, abdomen mild to moderate diffusely tender. No stridor, drooling or trismus. Uvula is midline.
Labs: CBC, BMP, LFTs, Lipase, HCG, & Mono screen.
Results: HCO3 19, Cr 1.4, Hgb 15, WBC 18,000, otherwise negative.
Cardiac Monitor: Sinus tachycardia with HR in 120s.
0.9NS 1 liter, Decadron 10mg, Morphine 4mg IV, Bicillin LA 1.2 million units IM given
With re-exam, the patient reportedly feels much better. She is now is smiling and overall comfortable appearing. HR 100, SBP 106, abdomen soft non-tender, mucous membranes glistening. The patient is discharged home.
Now examine the difference in documentation between two providers charting on this case.
Provider # 1
Differential Diagnosis: none listed.
Pulse ox Interpretation: Pulse ox 98%.
Cardiac Monitor Interpretation: none listed.
Medications: “Saline, Decadron, Bicillin LA”
Discharge Diagnosis: “Exudative Pharyngitis”
Provider # 2
Differential Diagnosis: “Strep throat, mononucleosis, peritonsillar abscess, dyspepsia, hepatitis, pancreatitis, pregnancy, ectopic pregnancy, sinus tachycardia, SVT, other”
Pulse ox Interpretation: “The pulse oximeter revealed 98% on room air which is not hypoxic and normal for the patient as interpreted by me.”
Cardiac Monitor: “The rhythm was sinus tachycardia with heart rate in the 120s as interpreted by me. The cardiac monitor was ordered secondary to the patient’s tachycardia and report of palpitations and to monitor for dysrhythmia. ”
Labs: “Labs – see chart / reviewed.”
Medications: “Normal saline 1 liter bolus, Morphine 4mg IV, Decadron 10mg IV, Bicillin LA 1.2 million units IM”
Discharge Diagnosis: “1. Exudative Pharyngitis, 2. Abdominal pain, 3. Nausea & Vomiting, 4. Dehydration, 5. Fever”
See the Difference?
- The latter documentation detailed the associated risk and complexity involved in this case.
- The appropriate differential diagnosis as well as the multiple diagnoses listed reflect the complexity of this case as well as the potential serious nature of the patient’s presenting medical problem.
- Listing the differential diagnosis also substantiates the appropriateness of the diagnostic tests that were ordered.
- This charting also indicates the provider was actively involved in the interpretation of data in the case. (i.e. “as interpreted by me” and “see chart / reviewed”)
- Finally, this documentation includes one of the therapeutic interventions that documentation guidelines recognize as “high risk”. (i.e. “morphine 4mg IV”)
Keep in mind – Optimal charting leads to Optimal reimbursement.
As a result of having the appropriate documentation, coders are able to code optimally.
When approaching our charting, we should acknowledge the complexity of the cases we manage as well as the detail of the care we have provided.
When proper documentation is performed, downcoding is avoided, and the appropriate level of reimbursement can be obtained by the provider for the service rendered.
Charting is our opportunity as physicians to appropriately detail the service that we have provided.
The goal is to obtain the proper compensation for the work that we do.
Optimize, not maximize — nothing more, and nothing less.