ED Coding and Reimbursement Alert

Although the CPT codes used in fast-track emergency department (ED) services are the same as always, the system of separate treatment tracks does raise some perplexing coding questions.

Not every ED uses a fast-track system, but they have become popular because they can lessen patient complaints, according to Jack Turner, MD, PHD, medical director for documentation and coding compliance, healthcare financial services at TeamHealth, an ED staffing firm in Knoxville, Tenn.

A fast-track system simply shunts some patients to a section of the ED designed for fast treatment, says Jim Pyron, DO, co-director of the emergency department at Freeman Hospital in Joplin, Mo. Its a section of the ED where people are triaged out of the normal ED and into an area where they take care of less-severe problems like coughs, colds or poison ivy. Normally things that are self-identifiable take fewer resources. It cuts wait time.

Although the treatment order may change, the treatment itself is the same, and coders can use the traditional codes. Evaluation and management (E/M) codes, however, can be affected depending on the policy at the hospital. In addition, some facilities use physician assistants or nurse practitioners for fast-track treatment, and coders must know who is providing the service to ensure correct coding.

Fast-track Creates Some Coding Confusion

The biggest coding question surrounding fast-track service involves visit codes. Traditional ED coding requires the use of 99281-99285 (emergency department visit for the evaluation and management of a patient) to reflect the five levels of service. Because of the nature of fast-track services, patients who go through this treatment track are unlikely to warrant more than a level-three visit code. But some facilities have started using outpatient office CPT 99201 - 99203 (office or other outpatient visit for the evaluation and management of a new patient) in place of the ED codes, Turner says.

For the first three levels of service, outpatient office codes pay more than ED codes under Medicare guidelines, with the largest differential at levels one and two.

ED physician groups dont agree with the use of office codes for fast-track services, Turner says, because they dont truly reflect the nature of the visit. Left to their own devices, most physician groups would rather use the ED codes. If we use office-based codes, we water down or diminish the severity of the treatment that goes on in the emergency room. Essentially, youre saying that the problem didnt need to be handled in the ED. As a result, the overall statistics of any given emergency department will show a move toward less-acute problems.

Now there are no official rules prohibiting facilities from billing office codes while physicians bill ED codes. In most cases, facility and professional-side charges are completely separate, and both can use whatever method they like. But Pyron, whose facility employs the ED doctors, says administrators at his hospital considered the issue a few years ago and werent comfortable with the use of two sets of codes. We were under the impression that if we used the same facilities and personnel to do this, we couldnt mix office and emergency codes. With a group of doctors billing totally separately, bills dont come in at the same time, but someone could get in trouble.

The new- and established-patient rules add another layer of complexity to fast-track coding. ED codes are designed to treat everyone as a new patient, Pyron says. To use office outpatient codes effectively, coders must be able to crosscheck every ED patient to see if theyve been to the hospital before. It just gets horribly complicated. Weve trained our doctors to keep up with the documentation requirements to meet the Health Care Financing Administration (HCFA) requirements, to avoid fraud. We tried to keep it as simple a system as possible, using ED codes like visit codes and critical care.

In some cases, facilities market fast-track services as a cheaper alternative to traditional emergency room treatment, Pyron says. His hospital now uses traditional ED visit codes and assigns a smaller conversion factor, thus lowering the charge.

For coders who work for just the facility or the physician group, the situation is simple follow the rules set by your organization. But for coders who handle both facility and professional coding, or who also do billing, conflicting orders are possible. In the event that youre told by the facility to use one set of codes or billing conversions for everyone, but the doctors want a different setup, stay out of the fight and refer the problem to your department head.

Will Rarely Be Used for Medicare Patients

Although fast-track coding is fairly simple under the Medicare outpatient prospective payment system (OPPS), there are two reasons why the issue isnt likely to arise very often:

1. Medicare patients tend to get sicker and are less likely to qualify for fast-track services.

2. People old enough to qualify for Medicare are less likely to visit the ED for minor problems. They are more likely to have family doctors and wait a couple days to see them, Pyron says.

Pyron estimates that Medicare patients will represent less than 2 percent of the people who use
fast-track programs.