ED Coding & Reimbursement Alert - 2020 Issue 2
Specialty Spotlight: Keep Your ED Coding on the Level With This Advice
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Article Overview
This article explains general documentation and review concepts for emergency department evaluation and management coding. It addresses how severity of presentation relates to coding level, why coders should rely on provider documentation, and how medical necessity, history, exam, MDM, and time-based critical care considerations fit into the review process. It is intended for coding professionals, auditors, and ED documentation staff who want a high-level understanding of the issues raised when assigning ED visit levels.
Why This Topic Matters
Emergency department records are often complex and closely scrutinized, so understanding the documentation expectations around visit leveling helps support accurate reporting and review readiness. The article is relevant for organizations seeking to strengthen compliance and documentation improvement in ED settings.
Article Sections
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Don’t Assume Trauma Equals High Level
This section discusses the idea that presenting condition alone does not determine the ED visit level. It frames the need to evaluate the encounter against CPT E/M guidance and the supporting record documentation.
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Read Note to Check Level
This section focuses on reviewing the provider note and the broader documentation elements used to support an ED E/M level. It also introduces Medicare’s E/M review tool and discusses how reviewers assess the encounter holistically.
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Reviewers Are Watching — You Should, Too
This section describes payer scrutiny of emergency department medical necessity and the importance of thorough documentation. It emphasizes documentation improvement and record clarity for both coding and future care continuity.
What You Will Learn
- How emergency department visit levels are reviewed at a broad documentation level
- Why the presenting condition alone should not drive coding assumptions
- What kinds of documentation elements are commonly considered in ED E/M review
- How medical necessity and record review affect compliance and audit readiness
- Why documentation clarity matters for both coding and continuity of care
Who Should Read This
- Emergency department coders
- Medical coding auditors
- Clinical documentation improvement staff
- Revenue integrity teams
- ED providers and practice managers
Codes Discussed
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