Best Practices to enhance Emergency Coding

Emergency coding requires a lot of understanding. It’s different from the other coding procedures. In-patient and out-patient codes won’t apply for emergency coding. The patient must be admitted in the hospital bed for an emergency and should be diagnosed with the procedures. Thus the process also differs when it comes to this particular coding.

Educated coders and healthcare professionals who are well aware of the variations and differences are essential for emergency coding. Delivering quality care, while ensuring effective clinical documentation and compliant medical coding, is an ongoing challenge in a fast-paced emergency department. In this article, we shall review best practices to optimize coding compliance and reimbursement of ED claims.

Educate healthcare Professionals on documentation requirements for emergency coding:

  • Educating emergency department clinicians on clinically significant and relevant documentation is the key to achieve compliant coding and optimizing reimbursement. This is especially challenging in the emergency department because the healthcare provider’s documentation must support the ED (emergency department) provider’s professional services, as well as billing and emergency coding for the facility.
  • The professional ED level just like other professional evaluation and management (E/M) services is based on the level of history, examination, and medical decision-making (MDM) documented in the medical record. On the other hand, the facility ED level is driven by the extent of services rendered by nursing and ancillary staff.
  • Healthcare providers must also be aware of the documentation requirements to support their professional services and specifically, the requirements of the patient history, exam, and MDM.
Levels 99281 99282 99283 99284 99285
History Problem-focused Expanded problem-focused Expanded problem-focused Detailed Comprehensive
Exam Problem-focused Expanded problem-focused Expanded problem-focused Detailed Comprehensive
MDM Straightforward Low complexity (Low) moderate complexity (High) moderate complexity High complexity
Nature of Presenting Problem Self-limited or minor problem low to moderate severity Moderate severity High severity not posing an immediate significant threat to life or physiological function High severity with immediate threat to life or physiological function
Clinical Example l Simple suture removal

l Uncomplicated laceration repairs

l Uncomplicated insect bites

Minor traumatic injury of an extremity with localized pain, swelling, and bruising (no imaging done)

Red, swollen cystic lesion on back

Rashes exposure to poison ivy

Visual disturbance with history of foreign body in eye

Minor head injury without loss of consciousness, altered mental status or amnesia

Asthma clearing with 1 nebulizer

Extremity trauma with X-ray

Asthma with >1 neb and/or X-ray/labs

DVT work-up (leg pain)

Vaginal bleeding, testicular pain

Migraine or low back pain with IV/IM and re-assessment

Greater than single extremity or organ system trauma

Chest pain with cardiac work up (EKG, X-ray/CT, labs); admit or discharge

Abdominal pain or kidney stone work-up and treatment that includes CT or ultrasound, IV fluids, IV/IM meds for pain

Most completed strokes, TIAs



  • Within the history component, the history of presenting illness is typically the weakest element of the documentation. Most practice management systems have in-built electronic health record (EHR) templates that can be customized to capture elements of the patient’s chief compliant.
  • The elements within the HPI are:
  • Location – Where on the body is the sign or symptom located?
    Quality – Describe the sign or symptom.
    Severity – Describe the intensity of a sign or symptom.
    Duration – How long has the sign or symptom been present?
    Timing – When does the sign or symptom occur?
    Context – What proceeds or accompanies the sign or symptom?
    Modifying factors – What reduces or increases the sign or symptom?
    Associated signs and symptoms – Describe co-existing problems that accompany the signs or symptom.
  • Even though it’s the healthcare provider’s choice to choose free text, rather than using the EHR templates, the latter aids in ensuring better documentation, while also educating the physician on the required elements.
  • Let’s have a look at the clinical example of an ED visit documented using such an EHR template. The bolded fields are now available on the EHR templates to cue the physician and to help improve documentation:
  • For example: A 76-year-old male comes to the ED with intermittent cramping, lower abdominal pain for the past 3 days following eating out at a local bistro, with 2 episodes of vomiting this morning. Denies fever, diarrhea, or bloody stools. Describes the pain to be 6/10 on visual analogue scale (VAS). Feeling better with aspirin.
  • Reason for visit –Abdominal pain
    Location of pain – Lower abdomen
    Quality of pain – Cramping
    Severity of pain – 6/10 (moderate)
    Duration of pain – 3 days
    Frequency of pain – Intermittent
    Timing of pain – None
    Context or onset since – Eating out at a local bistro
    Relieved by – Aspirin
    Worsened by – None
    Associated signs and symptoms – 2 episodes of vomiting this morning. Denies fever, diarrhea, or bloody stools.


  • Documentation cloning can be a huge problem while using EHR. For instance, the healthcare professional might use the same comprehensive documentation of physical exam for every patient/visit, even if such an exam is not pertinent to CCs. This questions the legitimacy and medical necessity of the service.
  • For emergency coding ED professionals must ensure that the documentation is pertinent to the visit.
  • Though the templates and shortcuts in EHR save the documentation time, it’s very important for providers to double-check the clinical information submitted to be certain that it’s relevant and unique to the patient’s current visit. Some EHRs have an audit trail feature to track historical information such as how often the documentation was cloned by pulling in previous entries.

Medical Decision Making:

  • Additionally, the work healthcare professional does including tests ordered and management options chosen, must be documented clearly because that information drives the level of MDM. On the facility side, special emphasis is required for documentation of start and stop times, mode/route of administration, etc., when handling hydration, injections, and infusions.
  • When rendering critical care services, providers most often miss documenting the face-to-face time spent on critical care.

Key areas that help select the facility ED levels in emergency coding:

  • There is no certain national standard that drives the facility ED level. CMS requires each hospital to establish its own billing guidelines, as restated by the Outpatient Prospective Payment System.
  • Many facilities follow a customized system. These points are assigned based on the  sufficient documentation for each of the grid parameters summing up to the final ED facility level to aid appropriate payment by Ambulatory Payment Classifications (APCs), which is the payment methodology under the OPPS.
  • Common types of services credited to the facility side include:
  1. Mode of patient arrival
  2. Triage
  3. Vital signs
  4. Nurse notes
  5. Nursing assessments
  6. Other assessments (airway, breathing, and circulation (ABC), visual acuity, pain, etc.)
  7. Psychological social status
  8. Isolation services
  9. Social worker notes
  10. Teaching time
  11. Care rendered towards colostomy, wound care, etc.
  12. Specimen collection (urine samples, throat swab, wound swab, etc.)
  13. Translator and interpret services
  14. Type of discharge disposition.


Emergency coding might be dealt specially. But all you need is accuracy and the people who handle it right. Medical billing companies are ready to provide incredible medical billing and coding services for a good business practice.


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