Why Hospitals Should Consider the Presenting Problem in their E&M Coding Algorithm

A patient’s presenting problem is an integral consideration to proper selection of the Emergency Department Visit Level and maintaining accurate coding principles.  The presenting problem is a window into the diagnostic complexity of an Emergency Department visit. It is also the intent of CPT©.

While there are always exceptions, the average patient presenting for evaluation and treatment of a sprained ankle will require less hospital resources than a patient who presents with chest pain and could represent an acute heart attack.  The facility resources that typically go into those two problems are starkly different. The nature of the presenting problem at Triage is the foundation on which immediate diagnostic testing, intensity of bedside nursing services and therapeutic interventions are carried out. Nature of the Presenting problem, or the reason for seeking emergency medical evaluation should be considered as an essential component of a hospital’s coding principles.

The ability to track the presenting problem of all patients who visit the hospital allows for the accurate financial projection of monthly or yearly reimbursements and costs.  It also allows for administrators to identify discrepancies between doctors or between coders.  Quality of care and accurate billing are crucial differentiators for today’s hospital.  Administration should be confident that all patients are receiving the appropriate workup and accurate charges.  The presenting problem is the key data element that allows administrators to compare performance of physicians, clinical support staff and coding staff.  Without consideration of the presenting problem these comparisons become difficult at best and inaccurate at worst.

1stHealthSystems’ StealthED codifies the potential presenting problems in a list of approximately eighty clinical groups.  To evaluate the diagnostic, therapeutic and outcome of patients, StealthED groups patients into similar clinical groups based on the structured list of presenting problems.  With this structured grouping of patients, the clinical and financial process can be compared and evaluated.  Evaluation and Treatment of ankle sprains should include a diagnostic imaging and application of splints at a predictable rate.  By comparing the diagnostic and therapeutic interventions by provider (physician) for the same clinical problem, variances in treatment patterns are easily detected.

The patient’s presenting problem is the key data element to group similar patients for outcome analysis.   Incorporating a structured presenting problem into the performance analysis is the essential key of this proven and data-driven proprietary coding algorithm.

by Mason A. Smith, MD