ED Coding and Reimbursement Alert

No legal requirement has more impact on the functioning of an emergency department (ED) than the federal anti-patient-dumping legislation known as COBRA/EMTALA (the acronym stands for Emergency Medical Treatment and Active Labor Act, passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986). This legislation requires EDs to provide a medical screening exam that is sufficient to rule out an emergency medical condition to each patient who presents in the department, regardless of the patients ability to pay. If a department fails to provide this screening, or provides medical screenings in a manner determined by regulators to be discriminatory, the consequences are severe. Physicians can be fined up to $50,000 per violation, and the hospital and physician can lose their Medicare participation.

Of course, federal regulators cannot be in the department checking over clinicians shoulders all of the time. If a complaint is reported, how will the investigators know whether the department complied with federal law? By checking the written documentation and medical record, of course.

It is up to the coders to ensure accurate recording of the CPT codes that indicate performance of an appropriate medical screening exam, as well as the ICD-9 codes of signs and symptoms that warranted treatment in the ED.

In addition, as the EDs primary contact with third-party payers, it is often the coding staff who must ensure that managed care plans who want to discourage ED utilization understandand properly reimbursethe emergency group for this federally mandated screening and care.

COBRA/EMTALA and Psychiatric, Substance Abuse Screening

It should be emphasized that it is the examining physician, not the insurer or managed plan gatekeeper, who determines whether an emergency exists.

For example, EMTALA protection also extends to intoxicated, suicidal or homicidal individuals who are determined to be dangerous to themselves or others. Such conditions must be identified by the ED personnel, and they must, under EMTALA, be treated if the patient is determined to be harmful to self or others. However, insurers often deny payment for psychiatric and substance abuse-related conditions. When these patients present with other medical conditions and require treatment by the emergency department staff (injuries, underlying medical problems, etc.), coders should identify these services with the appropriate CPT procedure and ICD-9-CM diagnosis code(s).

Then, when possible, the coders should advise payers of the federal EMTALA requirements that individuals with psychiatric and or substance abuse problems must be screened for emergency medical conditions and treated until they no longer pose a threat.

Triage is not Screening

A screening examination is required to determine whether an emergency medical condition exists. The routine triage assessment is not to be confused with a mandated screening examination. Triage determines the order in which patients will be seen in the emergency [...]