ED Coding and Reimbursement Alert

By Caral L. Edelberg, CPC, CCS-P
President, Medical Management Resources Inc.
Consulting Editor


With the publication of the outpatient prospective payment system/ambulatory payment classification (OPPS/APC) final regulations, the major controversy over required matching of the emergency department (ED) physician evaluation and management (E/M) level to the ED facility level was resolved with this statement, Therefore, we would not expect to see a high degree of correlation between the code reported by the physician and that reported by the facility.

The challenge to hospitals now will be to revise the existing facility assessment criteria that will crosswalk to the emergency department evaluation and management HCPCS codes in such a way that the full range of acuity managed by the nursing staff is reasonably reflected.

The final rule clearly states, We realize that while these HCPCS codes appropriately represent different levels of physician effort, they do not adequately describe non-physician resources. In the same way that each HCPCS code represents a different degree of physician effort, the same concept can be applied to each code in terms of the differences in resource usage. Therefore, each facility needs a system for mapping the services provided or combination of services furnished to the different levels of effort represented by the codes.

First review the content of the CPT emergency department E/M medical decision-making levels to assist coders in determining what facility services generally are provided with each level. This differentiates the various levels of care according to the patients presenting problem, the amount and complexity of data reviewed during the emergency department course, and the risk to the patient from the medical problem.

The four levels of decision-making straightforward, low complexity, moderate complexity and high complexity correspond to a certain level E/M code. Level-one and -two E/M codes, for example, require straightforward medical decision-making, whereas level-three codes require low complexity; level-four codes, moderate; and level-five codes, high complexity.

In essence, the emergency departments as managed by the nursing staff will be a key element in establishing the revised facility criteria for the crosswalks to the HCPCS billing codes.

Do A Self-audit

The revision of this criteria and the uniform use by all emergency department, coding and billing personnel will be critical to the future reimbursement for emergency services under APCs. The Health Care Financing Administration (HCFA) outlines in the final rule that billing information that hospitals report during the first years of implementation of the outpatient prospective payment system (OPPS) will be vitally important to the revision of weights and other adjustments that affect payment in future years.

HCFA will hold each facility accountable for following its own system for assigning the different levels of HCPCS codes and expect to see each facility follow its own rules. Therefore, auditing the code assignment for emergency department claims will be essential. Initially, random pre-billing audits will help to identify inconsistencies and address problems quickly. In addition, formal quarterly compliance audits will ensure that documentation and coding follow the criteria established for the emergency department facility services. Assistance in establishing chart audits is outlined in the table found on this page.

Medical Necessity: A Designing Component

Identifying medical necessity will continue to be a major component of coding and should be a consideration in designing assessment criteria after the APC implementation. To ensure that coding correlates to medical necessity, documentation provided by physicians and nurses should show objective identification of all services rendered and the reasons for those services often the patients presenting problem, signs and symptoms. Therefore, shortcut documentation will become a thing of the past as nurses develop check sheets to ensure that all elements of patient treatment are documented.

Although payment for many drugs and supplies will be bundled into the visit and procedure APCs, others will continue to be reimbursed separately. Therefore, it will be important to make sure that all chargeable items are identified for each patient and billed accordingly.

Medicare will bundle certain products, private payers generally will not. For inventory purposes as well as revenue optimization, all identifiable services and products should be identified clearly in the medical record for abstracting by the emergency department coders.

Identify Patient Resources

Perhaps the most challenging component of the APC regulations for clinical staff will be the new methodology for charging and receiving Medicare payment for individual procedure services. This means that all services provided in the emergency department, regardless of whether they are provided by an emergency physician assigned to the department, will be identified with appropriate HCPCS codes and billed to Medicare.

Although most existing facility assessment criteria take into account the resources provided to patients who receive the various levels and types of procedures, few actually identify these procedures on the claim form with charges for the facility resources. Coders, however, have been identifying any procedures performed in the emergency department as well as other outpatient sites, with HCPCS codes on the UB-92 form.

ED resource coding will be slightly different, as many of the services bundled into the CPT procedures for the physician billing component will be identified separately on the UB-92, whether as products or services.

Remember, the emergency physician may provide the E/M service and a laceration repair while the orthopedic surgeon stabilizes a fracture in the ED on the same patient. Each department will bill for his or her portion of the service on the billing forms, and the facility will identify all of the procedural services plus the medications and supplies used by both physicians.

Incorporating Modifiers

As of April 1, hospitals also are mandated to use the HCPCS modifiers similar to those used in the physician practices. The descriptors for these modifiers may be somewhat foreign to many hospital coders responsible for the ED, and some inservice orientation may be necessary to ensure their accurate use. The HCFA mandate for using these modifiers indicates some level of audit in the future.

We will hold each facility accountable for following its own system for assigning the different levels of HCPCS codes. As long as the services furnished are documented and medically necessary and the facility is following its own system, which reasonably relates the intensity of hospital resources to the different levels of HCPCS codes, we will assume that it is in compliance with these reporting requirements as they relate to the clinic/emergency department visit code reported on the bill.

We will all be challenged to learn more and be more accurate than ever before as a result of the new APC regulations. Physician and hospital coders must work collaboratively to address these emerging requirements and ensure accuracy across the board.

Four Easy Steps to Performing a Chart Audit 1. Senior staff randomly select a sample (at least 10 to 15 records per coder) each week and review them for accuracy. The auditors request copies of payment information for these claims to ascertain how the primary codes crossover to the APC assignments. At the same time, they review physician documentation, which allows them to select which doctors need orientation on the new requirements for outpatient coding. 2. The business office makes copies of the pages in the Medicare remittances that illustrate claims where coding problems exist, sends these back to the coders and possibly, the providers to address errors or deficiencies. 3. The facility documents outcomes and error rates, then advises coders of errors and asks them to review coding policies relevant to the errors. 4. Focused audits also may be necessary on hot coding spots i.e., critical care, modifiers, observation, high-end procedures, etc.