Evaluation and Management Services in the Emergency Department
Emergency department E/M coding rests on selecting the correct code family and then the correct level. Distinguish emergency department services from office/outpatient, observation, and critical care. Critical care requires a specified time threshold and documentation of the critical nature of the illness; it is not simply a sick patient.
For level selection, apply the current E/M framework: either medical decision making (MDM) or total time on the date of the encounter, whichever supports the level. MDM has three elements - number and complexity of problems addressed, amount and/or complexity of data reviewed, and risk of complications/morbidity. Time-based selection counts the provider's total time on that date, including bedside care and documentation.
Traps abound. Providers sometimes document a high level of data (e.g., ordering many tests) without addressing a complex problem, which does not automatically raise MDM. Reviewing old records or ordering tests that are not analyzed does not count as high-complexity data. Another trap is billing critical care for a stable patient who merely required close monitoring, or splitting time incorrectly when multiple providers see the patient.
Worked rule of thumb: if a patient presents with a complex problem requiring review of outside records plus interpretation of an ECG and labs, and the provider documents moderate risk with prescription drug management, MDM supports a mid-level visit. Verify the problem complexity, data analyzed, and risk all align before assigning the level.