Point Sheets Help Establish Valid E/M Levels in the ED

In the final rule creating OPPS, HCFA instructed hospitals to develop an internal system for mapping provided services or combinations of services to reflect the intensity or acuity of clinic and ED visits. Individual facilities are responsible for defining and then consistently adhering to the acuity-based criteria that determine their E/M levels. But HCFA gave little guidance beyond stating that services must be documented and medically necessary, and must reasonably relate the intensity of hospital resources to the different levels of HCPCS codes.

Because of this ruling, almost every emergency department in the nation has had to struggle with the question of how to assign value to ED services. Some are using point sheets, which help staff assign a set number of points for each service provided, and serve as a crosswalk or link from the facility level to the physician E/M-level codes.

How One Hospital Did It

Developing a point sheet requires understanding the amount of resources that go into each procedure, as well as interaction with the nurses who provide the services, according to F. Richard Heath, MD, FACEP, director of emergency services at the University of Pittsburgh Medical Center Braddock in Pennsylvania. While he was gathering information and interviewing staff, Heath thought about a process for establishing point sheets that would consider his facilitys operation and help satisfy HCFA requirements. The process, outlined below, seems to start and end with the people closest to the job.

1. Get information and feedback. Draw up a list of services and procedures hospital staff provide in the ED, then circulate it, ask for ED nurses comments and modify the list accordingly. Heath reports that the list was modified several times as other services came to his attention. The ED nurses do the work and know what needs to be on that list, Heath says. Our nurses do the charging and pick the E/M codes, so I oriented the point sheet to them rather than to the hospital coders.

2. Match points and E/M level to work. Consider each item and weigh how many points to assign it. I started looking at which types of patients we see in the ED and the kinds of things we do there. It should be fairly difficult for someone to bill a level five based on a relatively low number of procedures or relatively little work, Heath explains.

Heath also kept in mind HCFAs guideline that the level assigned should reasonably approximate the service provided. He tried to make the points assigned internally consistent so they would reflect the amount of effort involved regardless of where the service was performed. I had an internal feedback loop and, with that information, assigned points [...]

- Published on 2001-06-01