General Surgery Coding Alert - 2019 Issue 2
Reader Question: Know the Rules When Communication Problems Exist
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Article Overview
This reader question addresses emergency department evaluation and management coding when a patient cannot communicate clearly enough to provide a full history. It discusses how the situation affects history documentation, time-based reporting in the ED, and when coordination time with other professionals may or may not be considered. The article is aimed at coders, billers, and clinicians who document ED services and want to understand general payer treatment of added work in these circumstances.
Why This Topic Matters
Communication barriers can complicate documentation and create uncertainty about whether extra effort or phone time can be billed separately. Understanding the general rules helps avoid unsupported charges and supports accurate ED E/M reporting.
Article Sections
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Question
A scenario is presented involving an emergency department patient with communication difficulties and additional time spent coordinating care with prior providers.
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Answer
The response discusses general emergency department E/M reporting considerations, documentation of incomplete history, and payer treatment of time spent away from the patient.
What You Will Learn
- How communication barriers can affect history documentation in an ED setting
- Why time is generally not used to select emergency department E/M levels
- How added coordination time with other providers is treated in broad payer terms
- When critical care timing may differ from routine ED E/M timing considerations
Who Should Read This
- Medical coders
- Medical billers
- Emergency department clinicians
- Compliance staff
- Revenue cycle professionals
Codes Discussed
Code Ranges Discussed
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