ED Coding and Reimbursement Alert

By Caral Edelberg, CPC
ECA Consulting Editor
President, Medical Management Resources Inc, Jacksonville, FL

A new field on the UB-92 billing form, used by hospitals to report claims, will go a long way to help emergency department (ED) coders.

Hospital coders are traditionally trained to apply the most specific diagnosis available when reporting hospital charges. However, in the ED, it may be necessary to order many tests and perform many services to determine proper treatment for a patient.

ED physician group coders have often been instructed to assign the ICD-9 code that indicates the patients signs and symptoms if these problems prompted the performance of a test or service, even if the final diagnosis would not justify these tests.

This issue has been the long-standing focus of a national controversy between hospital and physician coders. There seemed to be no relief in sight until the recent decision by the National Uniform Billing Committee (NUBC) to mandate recognition of presenting symptoms or complaints as the admitting diagnosis for unscheduled outpatient visits. The decision becomes effective in April 2000.

Emergency physicians must comply with a federal law that states that every patient who presents to an emergency department must receive a medical screening examination (MSE), which is to include any necessary diagnostic tests and services sufficient to identify or rule out the presence of an emergency medical condition. Federal law further stipulates that this MSE must be provided regardless of the patients ability to pay for that treatment.

To guarantee the financial viability of the emergency care delivery system, payers generally accede to providing payment for even minimal screening services. The patients signs, symptoms and presenting complaints prompt the physician to order certain diagnostic tests and perform a particular level of history and physical examination in order to rule out a life-threatening illness and determine an appropriate disposition for the patient.

Medicare has long recognized the importance of presenting signs and symptoms, and prohibits its Medicare managed-care organizations from denying payment retrospectively based on final diagnosis (i.e., refusing to pay for services in the ED if the final diagnosis was not deemed a true emergency). Payment must be based on the patients need for treatment as demonstrated at the time of service, not after the fact.

Diagnosis Coding Rules and Who Sets Them

The rules for coding of outpatient services are centered on the American Hospital Associations Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office) revised October 1, 1995. The AHA rules suggest that coders list first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown on the medical record to be chiefly responsible for the services provided. Additional codes that describe any co-existing conditions should be listed. It goes on to say that codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when an established diagnosis or diagnoses have not been confirmed by the physician.

These rules provide the foundation for determining the ICD-9-CM codes for ED and other outpatient services. However, they fail to objectively address the ED dilemma.

Simply stated, the coding rules have not kept pace with the industry. If emergency departments are forced to treat on the basis of signs and symptoms, then payers must be forced to provide payment on the same basis.

Medicare and other large third-party insurers have policies that indicate they favor payment for appropriate screening services. With the way the current coding rules are written, however, how are payers to know why the patient really sought emergency services? What about the chest-pain patient diagnosed with gastritis after extensive history, physical examination and diagnostic tests rule out a potential cardiac problem? When the presence of an emergency is ruled out by the emergency physician, is does not negate the initial need for treatment.

Requiring emergency medicine coders to drop the sign and symptom codes when a final diagnosis is established wipes out the rationale for a significant portion of ED patients and results in significant payment denials. Unfortunately, the patient may be forced to pay for a portion of service.

The disagreement seems to center around the interpretation of the phrase reason for the visit in the AHA guidelines. In the ED, the reason for the visit is almost exclusively a sign, symptom or general complaint. Seldom is the diagnosis known prior to the history and physical exam or ordering of diagnostic tests. Only after examination and diagnostic study can the reason for the visit (sign, symptom or complaint) be confirmed as an established diagnosis or revised, after study, to establish a presenting diagnosis as another problem.

As establishing medical necessity for ordering of diagnostic tests demands recognition of the signs and symptoms necessitating the test and not the final outcome of the test, it should follow that the signs and symptoms that necessitate treatment and not the final outcome of that treatment should be considered in determining the necessity of the treatment.

Perhaps the recent decision by the National Uniform Billing Committee to include presenting symptoms and complaints on UB-92 billing forms for outpatient visits will resolve this issue when it becomes effective in April 2000. This all-payer revision to current policy, resulting from the Balanced Budget Act of 1997 (BBA) Prudent Layperson Protection provision, is the ammunition needed to force the change that common sense has long dictated in the ED coding environment.

Considering Medicare policy on payment for emergency medical screening in conjunction with federal law, as well as the ambiguity surrounding the phrase reason for the visit/encounter in the AHA coding guidelines, I recommend ED coders report the diagnosis codes for the signs and symptoms that indicate the reason a service or test was performed in instances where the final diagnosis alone does not support the test and/or level of service. Hopefully, when the NUBC decision becomes effective this confusing matter can be put behind us.