Compliance Series: The Untold Challenges of E/M Risk Determinations

By Linda Duckworth, CHC, CPC
Director, Provider Education & Advisory Services

The 2023 historic E/M guideline changes created uncertainty on a wide variety of decision-making topics amongst all specialties. One that Ventra Health has found to be most challenging for coders and clients is when to apply the high-risk “Decision Regarding Hospitalization (DRH) or Escalation of Hospital level of Care (EHC)” component. The primary culprit is the lack of attention it’s currently getting from payers and the AMA, leaving it vulnerable to overuse and misuse, resulting in potential over coding.

Clarification is needed for accurate and compliant coding.

Ventra Health is dedicated to coding in a manner that is accurate, compliant, and financially beneficial for our providers. All of this can be accomplished by adhering to the guidelines and staying abreast of updates as they become available. For this reason, we have done extensive research on when to apply DRH/EHC. We have reached out to Medicare Administrative Contractors (MACs), attended the AMA’s annual symposiums, and have contacted several industry-leading expert consultants. Even though each may explain a bit differently, there are common threads amongst all.

Q. Which providers can use Decision Regarding Hospitalization?

A. There is no limitation as to who (which specialty) can use DRH/EHC since they are circumstance- based choices for coding. For example:

  • Hospitalists can use the DRH component towards their initial visit when they are actively involved with decisions regarding the patient being placed into observation or an inpatient admission. However, DRH does not apply to subsequent days (coded as 99231-99232).
  • If there are decisions regarding escalation of care, such as moving the patient into the ICU for respiratory support, then the EHC portion of the component is used.

Also, DRH/EHC includes consideration of alternative levels of care. The AMA publishes this example:
“…may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment.” (source: CPT Evaluation and Management (E/M) Code and Guideline Changes, 2023)

Q. What must be documented?

A. The AMA has repeatedly said that they will not dictate how providers must document, often lending little assistance. Medicare is less shy with their expectations. In fact, WPS-GHA (a Midwest MAC) has adopted the term “proof of thought,” letting providers know that they need to clearly communicate their thought processes.

Using this as a guidewire, Ventra Health suggests that providers include a medical necessity statement explaining why the patient is being admitted, such as the need for observing/monitoring, or additional diagnostics, pain control, infusions, intensive nursing care or therapies. Consider starting the medical necessity statement with, “I spoke with the ED physician about placing the patient in observation rather than discharging home …” or “The need for hospitalization was discussed with the surgeon, the patient will be started on…” or “I am admitting the patient due to…” and then complete with patient-specifics. As always, we discourage providers from relying on an unedited templated statement or attestation that fails to convey patient-specifics. These types of documentation shortcuts lose credibility under payer audit.

Coders’ Limitations

Coders cannot apply Decision Regarding Hospitalization to an initial visit simply based on the concept that the provider “must have been involved since it’s an H&P.” The provider is still responsible for documenting proof of thought on the topic and must be actively involved in the admission decisions, not acting as a consultant for medical management for another specialty.

Medical Necessity

At the end of the day, regardless of the volume of documentation, coders and providers must bear in mind the medical necessity of every level chosen. Ventra Health stands by this mantra by being proactive with coder and provider education, performing ongoing quality assurance reviews, and relying on best practices from authoritative sources. Along with these extended efforts, we find that partnering with our clients is key to meeting compliance goals for both organizations, making our team a valuable asset to those we serve.

What's Next and How Ventra Health Can Help

Ventra Health takes compliance very seriously. The guidelines put forth by various regulating bodies, while sometimes complicated and almost always inconvenient, are not suggestions or optional. Our Provider Education team is launching this Compliance Blog Series to help you all understand the importance of compliance as well. Stay tuned for more educational compliance content from other Ventra experts.

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