Hospital Coders Are Key to Compliance

By Caral Edelberg, CPC, CCS-P
President, Medical Management Resources Inc.
Consulting Editor

As compliance issues relating to the APC system surface, hospitals have started looking to their medical records department to perform and/or audit coding of the hospital-based physician code assignment, particularly where the hospital performs the billing function for hospital-based physicians.

The Health Care Financing Administration (HCFA) has given hospitals the responsibility of developing their own facility charge level descriptions for outpatient departments. Many have developed systems that base facility levels on the physician evaluation and management (E/M) code descriptions. Although an improvement on the single-level criteria system used by some hospitals, physician E/M code descriptors are intended to describe physician services rather than nursing services.

Hospital coders who are asked to audit or assign physician codes must have a clear understanding of not only the CPT and HCFA documentation guidelines for history, physical and medical decision-making (MDM), but also the nuances of coding for each physician specialty. This is especially important when coding for emergency medicine a specialty that encompasses all areas: medicine, obstetrics, surgery, trauma, geriatrics and pediatrics, to name a few.

Coding For Clinic vs. Professional E/M

Professional coding rules for clinic evaluation and management services are quite different from the rules for coding the professional component of the
emergency department.

Clinic evaluation and management codes differentiate new and established patients; however, emergency medicine codes do not because all patients are considered new to an emergency physician.

Clinic E/M codes require knowledge of the typical time the physician spends performing each level of service, but emergency department codes (with the exception of the critical-care codes, 99291-99292) do not include time as an element. This is because emergency physicians are typically treating several patients within the same time frame and must prioritize patients according to severity of illness. As a result, a patient with a sore throat may wait longer for treatment than one with shortness of breath. To base an emergency patients visit on time may mean that the patient with the less serious and less labor-intensive sore throat (because he or she is in the ED longer) may have a higher code assignment than the more serious and more labor-intensive short-of-breath patient (because he or she is treated and discharged or admitted more quickly).

E/M services performed in the office/outpatient hospital area for new patients require that all three of the key components (history, physical examination and medical decision-making) meet or exceed the stated requirements for the code level selected. For established patients, two of the three elements must meet or exceed the stated requirements.

Emergency department evaluation and management codes also require that each of the three key components meet or exceed the stated [...]

- Published on 2000-11-01