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 overpayments to hospitals who billed higher levels of service than Medicaid deemed appropriate on retrospective analysis. Unfortunately, the controversy, when addressed nationally through such reputable sources as the Wall Street Journal, can be expected to spread and other states might expect to see similar audits. As a precautionary measure, ED physicians and their business office representatives might want to consider the following four steps to prevent further losses in revenue from similar payer actions:

1. Understand CPT language. Review CPT language for emergency department visits that specifically states, The levels of E/M services include examinations, evaluations, treatments, conferences with or concerning patients, preventive pediatric and adult health supervision and similar medical services, such as the determination of the need and/or location for appropriate care. Medical screening includes the history, examination, and medical decision making required to determine the need and/or location for appropriate care and treatment of the patient. This language should be used as a reminder to payers that screening can occur at any E/M level, not just the lowest. Unfortunately, screening terminology often is used by payers as a rationale for paying less when, in fact, the screening process often may encompass significant physician and nursing resources, diagnostic tests and ancillary supplies.

2. Review COBRA/EMTALA. COBRA/EMTALA language prohibits emergency department personnel from withholding treatment from any patient until the presence of an emergency condition has been ruled-out. COBRA further requires that any and all diagnostic tests available at the facility must be used to rule-out the presence of an emergency as applicable. This clearly indicates the critical importance of the emergency physicians judgment when providing the necessary level of care to the patient as determined by the presenting problem. Clarifications of the COBRA/EMTALA regulations jointly issued by the Department of Health and Human Services Inspector General's Office and the Health Care Financing Administration and published in the Nov. 10 Federal Register further underscore that Medicare and Medicaid managed care organizations are prohibited from requiring pre-authorization for treatment and must pay according to prudent layperson standards.

3. Watch out for downcoding. Billing departments should be on guard for routine downcoding of emergency department claims from appropriate levels of care to lower screening fees that result in significant losses in revenue. When downcoding occurs, systematic resubmission of claims in tandem with initiation of dialogue to address the larger issue of screening criteria should be undertaken to begin the process of educating payers and reducing losses. When possible, avoid a list of acceptable diagnoses (or related ICD-9 codes) that indicate payment as justifiable emergency conditions. This facilitates the downcoding of visits related to those conditions that are not on the list. Unlisted conditions can be downcoded to screening and paid at a lower amount. Inclusive as well as exclusive diagnoses lists result in significant payment problems.

4. Beware of minor emergencies. Emergency physicians and their billing staff should be cautious when encouraged to accept general screening levels for minor emergencies as the screening category often is abused by payers seeking to downcode based on final diagnosis and not the actual work done by the emergency physician. When all else fails, a well-documented copy of the medical record should be provided to the payer to establish the necessity for the higher level of serviceassuming, of course, that one exists. As always, physicians need to be cognizant of the importance of documentation in supporting the medical necessity of the service provided, particularly when the work exceeds the level generally provided for the diagnosis entered on the claim.