Make a Wise Reimbursement Investment Take the Time To Determine Acuity-based E/M-level Criteria

Facilities that are losing reimbursement for E/M services need to take a close look at their acuity-based criteria. Under HCFAs APCs, facilities are responsible for defining and then consistently adhering to the criteria that determine these levels, which, subsequently determine Medicare payment. For example, if a facility decides that any patient who receives an IV is at least a level three, staff should consistently code an IV procedure a level three. Hospitals must set the number of E/M levels and define standards for each. Its a complicated issue and, unfortunately, many facilities have poorly defined criteria and, to be safe, billers and coders report lower levels than they should.

In addition to the E/M-level issues, facilities are now billing for the separate procedures performed, such as laceration repairs and splint applications, even though the payment for most associated medications and supplies is bundled into the payment for the procedure under APCs.

Weve been in hospitals where 80 percent of the patients are coded as level one or two because the acuity criteria the facility uses to select the levels are not specific enough and open to too much interpretation, says Gregg Glinka, RN, a senior consultant for M. Leco and Associates, a coding and billing consulting firm in Pittsburgh.

For example, if a facility does not clearly state that an exam for sexual assault (which requires intense, extensive care by ED nurses) is a level-four E/M it most likely will be billed a level two or three. Obviously, payment at that level will not reflect the time and effort expended.

Know the Overall APC and E/M-level Picture

The guidance CPT provides for selecting emergency department E/M levels is physician-based and does not take into account the overhead costs a facility incurs
nursing time, room time, supplies that must be considered when determining a cost-effective level.

Start reviewing your E/M levels and acuity-based criteria at the root of the issue HCFAs current policy. Under APCs, EDs are paid for four levels of E/M services but can assign as many levels as necessary as long as they crosswalk to the HCPCS-assigned 99281-99285 series and 99291. CPT codes 99281 (emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem focused history, a problem focused examination, and straightforward medical decision making) and 99282 (... an expanded problem focused history, an expanded problem focused examination, and medical decision making of low complexity) are paid according to APC 610 (low-level emergency visits). Code 99283 (... an expanded problem focused history, an expanded problem focused examination, and medical decision making of moderate complexity) is paid according to APC 611 (mid-level emergency visits). Codes 99284 (... [...]

- Published on 2001-04-01