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PP4U:Medical Doctors' Coding Manual Items 7060 to 7064 for Emergency Department visits and how to code it.

 

 

Medical Doctors’ Coding Manual Items 7060 to 7064 for Emergency Department visits and how to code it.

- Anton van Schalkwyk (Medical Coding Specialist at SAMA)

(A Special note of thanks to Professor Mike Wells of the Emergency Medicine Society of South Africa [EMSSA] for providing his insights before this article could be submitted for publishing).

The Medical Doctor’s Coding Manual (MDCM) makes specific provision for Emergency Department patient evaluation and management services. These are the range of items 7060 to 7064. These items are sadly not yet been recognised by all medical schemes, despite of its functionality in distinguishing between a visit in the Doctor’s rooms and a visit to a 24-hour Emergency Department facility.

Medscheme has announced in September 2019 that they are going to accept items 7060 to 7064 for use by doctors providing services at 24 hour emergency facilities from 1 October 2019. They will now join Discovery Health in providing benefits for these codes that are designed specifically for 24-hour emergency departments. What makes these items so important, is that they align with the different degrees of complexities in the cases that are being seen in Emergency Departments. It basically focuses on three areas of the evaluation and management of patients:

(a) The history of the patient;
(b) The degree of problem focussed examination;
(c) The complexity of decision making;

These codes in the MDCM are aligned with CPT codes 99281 to 99285 and it is important to understand it in order to use it effectively in coding for services rendered.

There are five (5) different levels of service which are coded to, depending on the nature of the complaint to reflect the history obtained, examinations performed (including diagnostic testing required to make a diagnosis) and complexity of medical decision making. This set of codes recognise that 24 Hour emergency practices are centres of clinically diverse and complex nature.

What is of utmost importance to realise is that the coding of the emergency department doctor should not be influenced by the triage category of the patient. This system is only in place in the Emergency Department to ensure that the patient receives treatment within the right time-frame. It may be that a patient who was triaged green is more complex than many would assume. A green triage, in all its complexity, would only mean that this patient can wait to be treated, as opposed to a critically injured patient that needs to be treated immediately in order to prevent death from occurring, which would be treated as an orange or red triage.

Another mistake that is often being made, is that the code being used is strictly being linked with ICD-10 coding, meaning that the more severe the diagnosis, the higher the level of coding. Although ICD-10 coding is important and would most often serve as proof of the severity of the case, one must always remember that the complexity of a case being coded does not always equate the severity as displayed by the ICD-10 coding. The classic case of acute chest pain would be a good example. It could be a case of gastroesophageal reflux disease or it could be cardiac ischemia. It would only be through performing tests and therefore by a complex process of elimination that the correct definitive diagnosis could be made. An acute abdominal pain could be signalling appendicitis or something much less severe. When funders decide to link complexity and severity, they create a tendency on service provider level to up-code in order to receive benefits for cases where the process of elimination was more complex, even though the eventual diagnosis does not constitute an emergency. One should therefore take both severity and complexity and therefore also perceived severity into account when deciding upon the correct code to use. Furthermore, many patients who are seen in the Emergency Department do not receive a definitive diagnosis at the time of the initial presentation. Accurate and definitive ICD-10 coding is, therefore, often impossible.

This article does provide some examples that are based on guidelines within the CPT coding environment on which these items in the MDCM are based. Please take note that it should not be viewed as definitive rules, but rather as general, non-prescriptive guidelines in order to understand the functioning of the series of codes.

1. How to Code with items 7060 to 7064

Level 1: Item 7060:

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:
(a) Problem focused history
(b) Problem focused examination
(c) Straightforward medical decision making.

Counselling and/or co-ordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor.

This item is for straight-forward cases that are easy to diagnose or treat.

Examples:

- Item 7060 would be in line with an easy recognisable insect bite diagnosis.
- Follow-up visits for uncomplicated dressing changes, suture removals or the reading of results with easy instruction to the patient.
- Item 7060 would also be applicable for patients coming in for immunisations (e.g. tetanus toxoid immunisation after superficial injury was sustained).
- A patient coming in to request a sick note would also be coded with item 7060. This first level (Item 7060) makes provision for the easiest cases with a simple diagnosis. No additional testing or referrals are involved.

Discharge instructions would typically be straightforward, with no medications or home treatment required. The patient may return to the Emergency Department if problems develop.

This code would also be appropriate for straightforward follow-up cases.

Level 2: Item 7061

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:

(d) expanded problem focused history
(e) expanded problem focused examination
(f) medical decision making of low complexity.

Counselling and/or co-ordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low or moderate severity.

This item is coded for cases where the decision making is of low to moderate complexity.

Examples:
- Patients coming in with viral infections, such as flu would be a classic case.
- A patient coming in with a swollen cystic lesion.
- It could also be coded for minor injuries such as small lacerations that need sutures.
- A patient with minor traumatic injury of an extremity with localised pain, swelling and bruising, without the need for imaging.
- A patient presenting with a rash after contact with poison ivy or similar plants that cause irritation to the skin.

Level 2 coding (Item 7061) would for instance include the previous level (item 7060), but require obtaining more of the clinical history surrounding the complaint. Further there may be a need for example, for a urine or stool sample, visual acuity tests or blood sugar strip test or the application of a sling.

Discharge instructions in these cases are simple, e.g. over-the-counter medications or treatment and easy-to-understand instructions, e.g. simple dressing changes.

This code would be appropriate for the majority of follow-up cases which involve re-assessment and further clinical advice.

Level 3: Item 7062

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:

(a) expanded problem focused history
(b) expanded problem focused examination
(c) medical decision making of moderate complexity.

Counselling and/or co-ordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.

This item is coded for cases that need decision making of moderate complexity

Examples could include:

- Patients coming in with minor trauma being referred for X-Ray,
- A patient is brought with a head injury with local swelling and bruising. The patient does not present with any neurological symptoms such as confusion, loss of consciousness or memory deficit.
- Acute pain in the eye associated with a foreign body in the eye.
- A patient is being brought in with a sprained ankle and is unable to bear any weight on the injured foot.
- An otherwise healthy patient coming in with fever, diarrhoea and abdominal cramps, without vomiting.

Level 3 (item 7062) coding would include the previous levels (items 7060 and 7061). Referral for plain X-rays for one area (e.g. hand or pelvis), laboratory tests, simple fracture care or joint aspirations and injections would be indications for level 3 (item 7062). 

Discharge instructions are of moderate nature, which may include head injury instructions, crutch training, discussing the management of limitations to movement due to injury, prescription medication with some information of possible contra-indications, adverse or possible side effects, should the necessity arise. Patients may need to demonstrate understanding of the instructions provided as these cases are not simple in nature.

Item 7062 is expected to be used for the majority of patients presenting to the Emergency Department and could be considered to be the “baseline” code for the “average” patient presentation.

Level 4 Item 7063

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:

(a) a detailed history;
(b) a detailed examination
(c) medical decision making of moderate complexity.

Counselling and/or co-ordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the medical practitioner but do not pose an immediate significant threat to life or physiologic function.

This item is coded for cases of moderate complexity, but which need more detailed examination.

Examples:
 
- Patients with blunt/penetrating trauma with limited diagnostic testing.
- A patient is brought in with a head injury. The patient had a brief loss of consciousness.
- A patient who presents with vomiting and diarrhoea and is dehydrated.
- A patient is brought in with a severe headache with nausea and vomiting.
- Cases of dyspnoea requiring oxygen or respiratory illness relieved with (2) nebuliser treatments.
- A patient who is being brought to the Emergency Department with flank pain and haematuria. - Abdominal Pain
- with limited diagnostic testing.
- A patient coming in for a replacement of a percutaneous endoscopic gastrostomy (PEG) tube. - A patient was sexually assaulted and comes in for an examination without specimen collection.

Level 4 (item 7063) coding would be in cases where, for example, the patient was referred for specialised radiology, multiple basic radiology, more than one diagnostic tests (e.g. laboratory, CT, EKG, X-ray) were involved. Patients where nasogastric or PEG tubes had to be placed, replaced or administered or monitored could also possibly be considered level 4 patients.

Discharge instructions are of moderate nature, which may include head injury instructions, crutch training, discussing the management of limitations to movement due to injury, prescription medication with some information of possible contra-indications, adverse or possible side effects, should the necessity arise. Patients may need to demonstrate understanding of the instructions provided as these cases are not simple in nature.

Level 5 Item 7064

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and mental status:

(a) comprehensive history
(b) comprehensive examination
(c) medical decision making of high complexity.

Counselling and/or co-ordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

Item 7064 is coded for complex cases that requires comprehensive examination:

Examples:

- Patients coming in with blunt/penetrating trauma requiring multiple diagnostic tests.
- Cases of systemic multi-system medical emergency requiring multiple diagnostics.
- Patients brought in with severe infections requiring IV/IM antibiotics.
- Cases of uncontrolled Diabetes Mellitus.
- Patients coming in with severe burns.
- Hypothermia.
- Patients coming in with severe headaches requiring a CT and/or lumbar puncture.
- The classic example of patients coming in with acute onset of chest pain and symptoms that seem like cardiac ischemia and/or pulmonary embolus, requiring multiple diagnostic tests/treatments.
- Patients presenting with upper gastrointestinal bleeding.
- Patients brought in immobilised, with possible intra-abdominal injuries or polytrauma or other major musculoskeletal injury.
- Respiratory illness necessitating multiple nebuliser treatments (three or more).
- Patients presenting with high fever, shortness of breath and an altered level of consciousness.
- Acute abdominal pain requiring multiple diagnostic tests and/or treatments.
- Acute peripheral vascular compromise of extremities.
- Neurological symptoms that require multiple diagnostic tests and/or treatments.
- Patients who ingested toxic substances.
- Serious mental health cases, including patients who attempted suicide.
- Sexual Assault Examinations that include specimen collection.

Level 5 (item 7064) patients would include previous levels of intervention (items 7060-7063), but could also include cases where three or more diagnostic tests were performed. It could also require frequent monitoring of multiple vital signs. Procedures such as central line insertion, gastric lavage or paracentesis could be indications of Level 5. It would also include critical care less than 30 minutes.

Discharge instructions of complex cases may include multiple prescription medications or therapies. Many of these cases may involve serious chronic or other conditions such as diabetes, epilepsy or asthma and therefore discharge may involve some teaching regarding non-compliance with additional information being provided to caregivers or patients in cases where they display some difficulty to understand.

In patients with physiological instability requiring some form of resuscitation with the doctor present an additional critical care code would be used.

As seen above, the levels of coding as displayed in items 7060- 7064 are very well formulated to code for Emergency Department evaluation and management services. We do urge Medical Schemes to review the practical benefits of recognising these codes for use within the clinical setting it was designed for. It is the intention that the correct code is used for the correct patient in all circumstances, as supported by the underlying CPT principles. That does mean that the correlation between triage and coding might not be straightforward, but it also means that patient admission or discharge might not always correlate with the coding. For example, patients who are extensively worked-up or managed in the Emergency Department might be billed at a higher code, but still discharged. It will remain the treating doctor’s responsibility to ensure that the clinical records support the decision about which level of care is used.

2. General Coding Guidelines
• Only one of items 7060. 7061, 7062, 7063 or 7064 may be used per visit and not combinations thereof.
• Add-on Items 0145, 0146, 0126, 0147, 0148, 0149 and 0129 may not be added to items 7060 to 7064. It is important to note that these add-on codes specify all the primary visit or consultation codes they may be added to.
• Items 7060, 7061, 7062, 7063, and 7064 were specifically developed for use by 24 Hour emergency practitioners (Pr 035) and general practitioners who are working at such emergency facilities. It may not be used for services at the doctor’s own practice.
• When a specialist of any other discipline is rendering a service at a 24 Hour emergency department, the normal consultation items 0190 to 0193 apply with the appropriate add-on codes for emergency and unscheduled visit codes.
• An emergency department is defined as a facility for the provision of unscheduled episodic services to patients who present for immediate medical attention and emergency diagnosis and treatment of illness or injury is provided. The facility must be available 24 hours a day.
 
Bibliography:
1. CPT Professional, 2019 Edition (American Medical Association), Appendix C – Clinical Examples
2. American College of Emergency Physicians Website: https://www.acep.org/administration/reimbursement/ed-facility-level-coding-guidelines/

The South African Medical Association - Postal Address-The South African Medical Association P O Box 74789,Lynnwood Ridge Pretoria 0040, South Africa Physical address The South African Medical Association, Block F Castle Walk Corporate Park Nossob Street Erasmuskloof Ext3 Pretoria 0181,
South Africa www.samedical.org

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