ED Coding and Reimbursement Alert

Should your emergency department (ED) or emergency physician group accept set screening fees and/or unique screening codes from third-party payers for low-level, non-emergent services? Or are you better off insisting on coding each service individually and risking denials based on lack of a specified emergency medical condition?

Background

Federal lawspecifically the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA)requires EDs to provide all patients who present in the department requesting care with a medical screening examination (MSE) that is sufficient to rule out the presence of an emergency medical condition. With the increase in managed care in the early 1990s, payers often retroactively denied payment for non-emergent care provided in the ED, even though EMTALA requires clinicians to provide it. The solution some payers and emergency groups devised was to set up a low, standard fee for non-emergency screening, which was to apply to the MSE provided to patients who seek treatment in the ED for low-acuity problems.

Payers May Determine Screenings Retroactively

Recent headlines involving Florida Medicaidwhich published a study accusing Florida hospitals of overcharging for common emergency department caseshighlight a common problem. (See insert in January issue of ED Coding Alert.) The study contends that the 10 most frequently billed diagnosesmost notably ear infections, fever and upper respiratory infectionswere over-billed by Florida emergency departments as determined by Medicaids own internal audit. In Medicaids opinion, these non-emergency cases should have been billed as screening exams and paid at significantly lower reimbursement amounts.

The screening category assigned by the payer is based on findings after treatment, not on the signs and symptoms that necessitated the level of care provided in the ED. As most emergency medicine personnel are aware, and consistent with COBRA/EMTALA and Medicare payment guidelines, the emergency status of a patient is determined prospectively, not after the work has been done to determine whether an emergency condition exists. Therefore, determining the legitimacy of coding and subsequent payment on the final diagnosis and not the presenting problems conflicts with the foundation of emergency service.

At first glance, a screening fee seems a sure way to guarantee at least some payment for low-level ED services. A growing number of payers began to downcode many essential ED services as screening exams and the specialty began to experience considerable declines in revenue as a result. Hospitals and ED physician practices found that more staff resources were necessary to resubmit many inappropriately downcoded claims as payers used the screening category to retroactively reduce payment for services that were provided appropriately based on presenting problem and symptoms when the resulting final diagnosis was considered a non-emergency.

Protect Yourself

In Florida, Medicaid has stated that they will not seek reimbursement for the estimated $5.5 million in calculated [...]