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Posted By jan on 10-04-2001, 16:20:00 in Emergency Department


OK LISt,
I am opening myself up to alot of "is she nuts " comments, but I
really need some input, so be gentle but any help is welcome.

If our ERMD does the CS for another MD, most often an orth MD, ( I'm
not coding CS for our MD. I am also not coding anesthesia codes. I have
been down that road and beleive me bottom line among other reasons,is
anesthesia has exclusive contract in hospital to charge for anesthesia
services. So we will rule that out, as an option.
Senerio, child breaks distal radius , it needs reduction. ERMD
evaluates pt, does xray, sees break,(no I can't code for xray interp
either ,anothe exclusive contract) says to MOM and pt it's broken, then
consults family MD or ortho on call and the ortho MD comes in and does a
reduction. The ERMD documents 4 HPI, 10 ROS, 2 PFSH, 8 exam elements,
plus the ASA level risk and benefits, at bedside for 20min while under
deep sedation, conscious sedation protocols for our hospital followed,
pt was given IV sedation with whatever it took, IV, pt status post
sedation and finishes chart with outcome of reduction, discharged with
instructions per ortho, and really wonderful documentation everything that
you could think of is covered in this documentation.
I am having difficulty in justifying the Level 5 because the injury is
not life threatening, and is repaired by another MD. granted there is
consultation involved, but where does the giving the IV med( or having
the RN give the med and he supervises, right there,) and supervising
conscious sedation fit to a Level 5.Or does it??
Can just a procedure justify a higher level just because it is
complex.?? See where I'm having difficulty?
Anyone want to bail me out of this dilema???
Truth is I want to code a level 4, not 5. HELP
Comments (7)
Posted By cheryl on 10-08-2001, 15:47:00
Thanks Michelle.
This is the same "score sheet" we use that I referenced earlier.
Posted By cheryl on 10-08-2001, 15:43:00
Part B news published this in March 1998.
Posted By michelle on 10-04-2001, 21:06:00
Here is Pennsylvania Medicare's Audit tool (scroll down to HCFA-8985 and
download):

http://www.hgsa.com/professionals/forms.shtml

Please note that each carrier may have a slightly different audit tool. For
instance NHIC's MDM points differ from HGSA's, as well as their definitions
of a "detailed" examination. It would be nice if they were all identical.

Michelle Reckleff, CPC
Vice President, Coding & Compliance
Physicians' Choice, LLC
Posted By cheryl on 10-04-2001, 20:36:00
I am jumping in here without reading all the threads of discussion.
This is a high risk but that alone does not support a 99285.
To meet the requirements of a 99285 in the Medical Decision Making portion of the E/M you have to meet or exceed 2 out of 3 in
DX/Treatment Options
Amount and Complexity of Data
Risk
Using the audit tool designed by HCFA (CMS) you need 4 or more points for a high level in Dx/treatment options and/or amount and complexity of data in addition to the high risk.
Posted By martin on 10-04-2001, 20:22:00
Well I think the risk and complexity of decision making in sedating a
patinet is certainly high complexity.It doesn't require the injury to be
complex just the risk in the sedation. At least we bill level 5 for all
sedations if we are supporting another physician.

Martin Herman, M.D.
Memphis
Posted By jan on 10-04-2001, 19:06:00
ERMD DID DO ACTUAL SEDATION, BUT ORTHO DID PROCEDURE, ANESTHESIA WON'T
CHARGE FOR THIS SERVICE, AND WE WON'T USE ANESTHESIA CODES BECAUSE ON
CONTRACT ANYONE SEEN IN OUR HOSPITAL WILL ONLY HAVE ANESTH CODES CHARGED BY
ANESTH. I won't code the CS code unless ERMD does procedure too, so it
feels like a lost service. In an audit I could not support the upcoding,
However since Medicare does not recognize it as a service, separately
payable , I don't know who I would defend it to, but like Dr. DeHart says,
if it does not pass the "sniff test", then don't. He has nothing to do with
this issue, but always uses that term when talking about coding in his
lectures. Botton line I'm coding a level 4 and trying to talk the ERMD's
into getting anesthesia to come and do these sedations. (Fat chance but ..)
Thanks all for answering this question, you were all very gentle and did not
bruse my ego at all.
Thanks for being out there.
Posted By Francis on 10-04-2001, 18:34:00
I will not charge CS, not done by ERMD, ortho does it, just a 99284
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