ED Encounters: Beware Miscoding Complexity in the ED

Why This Topic Matters

Emergency department claims can be difficult to code accurately when the documentation does not clearly show the clinical complexity of the encounter. Understanding the documentation elements discussed in the article helps coding and audit staff better evaluate whether the record supports the level assigned to an ED E/M service.

Article Sections

1. Stay Wary of Lacking Documentation on H&P

   This section discusses the role of history and physical examination documentation in emergency department E/M records and why incomplete encounter forms can create coding challenges.

2. Find the Proof in the Paperwork

   This section focuses on how the documentation should reflect the complexity of the visit and the acuity of the emergency department setting.

3. Focus in on Cause and Treatment Specificity

   This section addresses the need for documentation to show what is being treated and how other conditions may relate to the encounter.

4. Follow the Journey from Presentation to Dx

   This section covers how the patient’s presentation, work-up, and evolving assessment are reflected in the record when determining the level of an ED visit.