# ER Facility Billing



## afrunk (Jan 31, 2011)

What are the coding guidelines for an ER bill on a UB92 that both the physician and the facility are billing CPT 99283.  I know that the ER physician can but is the facility supposed to use CPT codes for ER billing?  Thank you.


annespangle@yahoo.com


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## kevbshields (Jan 31, 2011)

Yes, the facility's report E/M codes to describe their services.

Here is some information on that.  Unfortunately, facilities are still waiting for CMS guidelines on how best to establish/score the facility E/M levels.

http://www.ahacentraloffice.org/ahacentraloffice/images/EM_Coding_Report2.pdf


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## mitchellde (Jan 31, 2011)

what Kevin has stated is true, there is no established set of facility guidelines for E&M codes, However there are guidelines that state the facility is responsible for creating their own set of guidelines to establish their E&M levels, there are some rules for this that state the guidlines need to be objective, and applied neutral to all patients, if an activity can be accounted for with a CPT code then it cannot be included in the assessment for the E&M.  Also it cannot be time based.  Your facility should have such a tool already in place to establish the level of service.


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## Dorothy Steed (Jan 31, 2011)

Code levels typically determined by using a point system to capture resources.  In absence of standardized format, facilities should be realistic and consistent in the point assignments.


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## kevbshields (Feb 1, 2011)

As Dorothy mentions, there is a "point system" in use.  The ACEP method is also popular.  I'm more inclined to use ACEP because the point systems I've seen tend to derive from separately reportable CPT and adjunct services (e.g., 1 point for a patient getting an x-ray, 2 points for one getting a wound/injury closure, 1 point for an IM injection).

Honestly, in looking at how facilities determine their ER E&M levels, I find a great deal of inconistency.  From some of my auditing jobs, hospitals tend to score everyone 99284 and 99285.  They have an even more difficult time pointing toward how medical necessity supports that level.  Even so, without explicit, tried and sound methods, this is what payers have to contend with . . .


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## mitchellde (Feb 1, 2011)

The point systmes work however you have to be care in that if the activity can be coded with a CPT code then you cannot assign points so an IM injection has a CPT therefore you cannot assign points to it, the xray is fine because at least where I worked the points were asigned to account for the patient transported, the xray code included the tech.


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## jimbo1231 (Feb 2, 2011)

*Major Variances*

Kevin,

Your observations are correct from what I've seen. There are major variations in Facility ED levels among similar EDs. I've looked at several EDs with similar patient mixes and demographics with wide variances in where their Levels are landing. Some will have the majority of their codes at 99283 or under. Other's will be weighed way more to the higher Levels. This is based on Medicare data...so payor mix which could be a factor in ED Levelling acuities isn't. My thought is that it depends on the coding methodology, who is doing the coding, and whether they do it themselves or outsource.
I'm wondering if in your auditing you've found something similar. My general thinking is that without standard Leveling guidelines; ED Levels are all over the place...Overall I also like the ACEP approach best since it factors in several elements and builds on the last level. I think it's closer to coding than point systems which can be OK but you better do your math right for them to work.

Jim S.


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## kevbshields (Feb 2, 2011)

You know, I replied in this discussion because I've spent some time looking at the blatant variances and how very obvious they are.  Also, in having used a couple of these "home grown" point systems (which may or may not consider separately identifiable CPT into their calculations) and comparing that to the ACEP, I wanted to share professional preferences . . . At this point, as I progress academically, I'm going to consider using this very topic for a thesis later along.

I doubt that by the time I graduate CMS and the payer realm will have worked this out much than is currently in place; thus, what a terrific project!  

It's also encouraging to see other coders finding similar variances.  As Jim pointed out, the acuity level rarely seems to be the basis of the ER code level.  Great example, I recently saw two cases in separate EDs.  One was for numbness and stroke-like symptoms--coded as 99285.  The next case was a series of fractures, one in the extremities and the other closed head--coded as 99282.  Makes no sense.  

Anyhow, thanks everyone for sharing your thoughts.


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## jimbo1231 (Feb 22, 2011)

*Variances*

Kevin,

Those examples are typical of what I have also seen. I've been trying to get the message out about facility levelling (infusions are a big mess too...another story!) through mailings to hospital managment and the articles in Coding Edge. But the response from hospital personnel has been luke warm. It seems that the ED is still way down the list for many hospital CFO types even though it is easy to show them they are losing revue if levels are way low or risking eventual RAC if they are way high.
Just wondering what your experience has been. It sounds like you are in school...some kind of MBA?; but also working in the field with all of those certs.
Wondering if you would like to talk off line about where we might have some common ground. I'd be happy to send you more info about me.
My E is straffcon@aol.com; web site is www.straffordconsulting.com

Jim Strafford   CEDC   MCS-P


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## keke74 (Feb 22, 2011)

Hello everyone. I only have experience coding the ER professional services, but I'm finding that most employers are looking for experience in both Professional & facility. I would like to gain experience on the facility side as well. I do have experience with infusion/hydration coding which is a big component of ED facility Coding. I have googled ED facility Coding & found some information that was helpful & I have a copy of the ER facility guidelines from ACEP website. I  obtained the CEDC credential a few months ago & I really don't want to just limit myself to Professional services only. The questions I have is in regard to the APC levels. How do you determine the APC level Type A or Type B? Also, is Icd-9 Vol.3 required with ED Facility Coding? Oh & 1 more question, is there ever a time when the Professional E/M is the same as the Facility level E/M? Any help would be greatly appreciated.


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## mitchellde (Feb 22, 2011)

A Type A ED is open 24/7 and uses CPT E&M codes 99281-99285
Type B ED is not open 24/7 but still has EMTALA reqirements it must meet, and use HCPC II  G codes for the E&M levels
ICD-9 Vol 3 codes are not used in the ER or any outpatient department, they are for the reporting of procedures for the inpatient billing only.
Any time a physician level and a facility level match it is coincidence only.  The physician uses the 95/97 guidelines and the facility use the criteria they create to obtain the visit level.


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