Consider the Service Provided to Code ED Medical Screening Exams at a Higher Level

Why do emergency departments (EDs) have coding and reimbursement problems with medical screening exams (MSEs)? Why are they consistently coding MSEs at the lowest level (99281)? HCFA expects coders to report ED MSEs with an evaluation and management (E/M) code. In addition:

CPT establishes, ... the levels of E/M services include examinations, evaluations, ... such as the determination of the need and/or location for appropriate care.

Most payers reimburse ED MSEs; some states require that all payers reimburse.

Under the Emergency Medical Treatment and Active Labor Act (EMTALA), EDs must perform an MSE for anyone who enters its facilities with a perceived medical condition.

Let the Services Determine the E/M Level

Caral Edelberg, CPC, CCS-P, president and CEO of Medical Management Resource Inc. in Jacksonville, Fla., says EDs arent getting reimbursed for all the work they have to do during a screening because they automatically set their MSE E/M at the lowest level. You should never automatically assign a low level to an MSE, she explains. You need to let the level of the services you provide the history, exam and the medical decision-making determine it. Often a screening exam is a level three or higher. Edelberg explains the confusion about MSE coding. An MSE is a government-required service designed to rule out an emergency problem. Under EMTALA, the ED is required to perform an MSE before the patient can be discharged or transferred to another site of service, Edelberg says.

EMTALA also sets the definition and examination requirements for an MSE. However, facilities or hospitals determine who will give the exam. Many hospitals perceive ED MSEs as a cursory check for symptoms that nursing staff can provide and, consequently, set the E/M level low.

This approach, however, does not consider liability. The hospital is liable when it makes a determination that the patient is stable, says Mason Smith, MD, FACP, CEO of Lynx Medical Systems in Bellevue, Wash. An emergency physician on duty should always review the medical information and examine the patient before discharge, even if someone else conducts the MSE. Therefore, its crucial not only for coding but for potential liability that an ED do everything necessary to stabilize the ED patient and document the event in great detail.

Policy-makers often are unaware that what begins as a routine MSE could turn into a high level of service. The level and content of the MSE needed to determine the presence of an emergency might actually be the treatment, Edelberg says. By the time youve provided the history and physical, ordered and interpreted diagnostic tests and provided discharge instructions and, in many cases, a prescription, youve done everything that needed to be done.

Lets [...]

- Published on 2001-03-01