ED Coding and Reimbursement Alert

Nugget: Hospitals will be required to identify all services provided to the patient during an emergency department visit when the ambulatory payment classification rules take effect on Aug 1, 2000. With this inevitable change, optimum reimbursement will be gained only with a clear understanding of the APC coding process.

By now many of you are breathing a big sigh of relief that the implementation of the ambulatory payment classifications (APCs) of the outpatient prospective payment system (OPPS), has been postponed by HCFA until Aug 1.

Since the release of the APC final rule, many coders have received numerous inquiries from hospital administrators relating to use of the emergency physician CPT codes for assigning the hospital emergency department (ED) assessment levels and procedures. Although this might seem like a natural correlation, the general information available for comparison of physician and facility coding criteria and analysis of the final APC rule indicate that it is not in the best financial interest of most hospitals to code in this manner.

Additionally, use of the distinct emergency physician codes may result in compliance issues due to incomplete code assignment for the hospital portion of the service due to the reasons outlined below.

Under APCs, the hospital will be required to identify all services provided to the patient during the emergency department stay. In numerous cases, the emergency physician is but one of two or more physicians who may examine and treat the patient.

The ED facility level, as well as the codes for the surgical and other procedural services, must reflect the full package of services provided, not just those services performed by the emergency physician. Therefore, in many instances, the emergency department facility level may exceed the level billed by the emergency physician.

Due to coding constraints placed on physicians when their documentation does not meet or exceed established documentation guidelines, emergency department coders may be forced to down-code the emergency department levels by one or more codes. These constraints do not affect the hospitals coding of the emergency department facility level. For example, the medical decision-making level in both physician and nursing documentation indicates a moderate level evaluation and management (E/M code 99284), but the physician provides a more limited history and physical examination that would result in a lower physician code (99283).

Most coders and ED practice administrators provide educational programs to their emergency physicians, but due to the hectic pace in the emergency department and, on occasion, the limited time a physician has to document a complete medical record prior to the patients discharge from the ED, certain components of the documentation may occasionally be omitted. Use of these down-coded levels will result in a negative financial impact on the hospital.

Time-Based Coding

The emergency physician coding and billing process does not operate under the same time constraints as that used by the hospital. Therefore, a longer period of time might exist between the generation of the medical record and the generation of the bill for the ED physician services. Use of the emergency physician billing codes might delay billing of the hospital charges and decrease hospital revenue.

Hospital administrators desiring to use the ED physician codes should be cautioned about potential significant compliance issues. There is no established crosswalk from the physician code descriptions for the physician evaluation and management services to their use in describing emergency department facility resource levels.

As HCFA has indicated in the final OPPS rule, they do not expect to see a correlation between the physician and facility levels. The hospital is expected to establish its tiered facility assessment criteria and assure that it is used consistently and uniformly in identifying emergency department visit levels.

The cumulative value of the emergency department resources provided by emergency physicians, consulting physicians, nurses, ancillary staff, and the cost of overhead (room, equipment, indirect expenses, nonchargeable supplies, etc.), will exceed the level of resource provided solely by the emergency physician. Use of physician codes would frequently result in lost revenue to the hospital by undervaluing the ED facility service.

Under APCs, the hospital must unbundle and separately identify procedures from the facility assessment criteria and bill them separately. They will, in turn, be paid under the assigned APC payment rate for each procedure often in addition to the payment for the assessment level or evaluation and management service when the -25 modifier is appended.

The surgical and diagnostic procedures that must be identified on the UB-92 for hospital billing must include all procedural services provided throughout the ED visit, not just those performed by the emergency physician. Thus, valuable charges would be omitted from the total ED charge by using the emergency physician codes when attending physicians come to the ED to provide those services.

Steps to Smooth Transition

How can emergency department coders help the hospital to identify how significant these differences might be? Perform a mini-audit by following these four steps:

1. Identify a sample of emergency department records in which the attending physician came to the emergency department and performed operative procedures (laceration repairs, orthopedic procedures, cardiac procedures, etc.)

2. If possible, assign codes to the services provided by both the emergency physician and the private physician.

3. Compare the physician coder assigned codes to the hospital facility coder assigned codes.

4. Compare the code assignments, which should include both ED and private attending physician operative services performed in the ED. Discuss the differences with the hospital coders and administrators.

The following problems may prevent accurate coding of facility services:

Hospital coders may not interpret the surgical coding rules the same way physician coders do. Although required to follow the Correct Coding Initiative (CCI) edits, they may not be as aware of the HCFA and AMA guidance provided in the past relating to the nuances of coding for these services. Therefore, differences are bound to occur. See section MCM15068 of the Medicare manual for an outline of these rules.

Physician coders may also find that modifiers commonly used by physicians are used differently in the hospital environment. ED physician coders and ED hospital coders will have to agree on how they will be used uniformly and accurately, particularly the -25 modifier (significantly separately identifiable evaluation and management service on the same day as a procedure or other service), which will help assure appropriate payment for the facility level identified with a HCPCS/CPT E/M code when a procedure is billed. Remember, with APCs, the facility payment will be based on the facility level and the surgical and diagnostic procedures performed in the ED by all physicians.

Hospitals may tend to undervalue (undercode) the facility level based on the final diagnosis, not the presenting problem signs and symptoms (headache, abdominal pain, chest pain, etc.). When these problems do not end up as emergent problems after the ED work-up was provided and an emergent condition was ruled out a potential loss in revenue can happen. Hospitals coders generally focus on the final diagnosis, not the presenting problem, and may need some assistance in developing a system to score the facility level primarily on medical decision-making and ED course rather than the final outcome.

Keep the lines of communication open. ED physician and ED hospital coders have a lot to learn from each other and should grow to be close allies as the APC program gets under way.