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 department. The screening examination must include the same diagnostic testing that would be performed on any individual presenting with the same signs and symptoms, regardless of ability to pay.

Coding of signs and symptoms has always been an important component of coding for ED services in order to illustrate the signs, symptoms and conditions that necessitate treatment within the department. EMTALA regulations enforce this ED coding premise by focusing on the reason for the visitnot the outcome or final diagnosisas an indication for the screening exam and stabilization of the patient prior to transfer.

In other words, signs and symptoms that indicate a potential threat to the patient take precedence over final diagnosis as a condition for necessity of ED care.

To ensure that necessity for emergency treatment is established and the payment for service is appropriate, ED coders must address the patients chief complaint by coding not only the discharge diagnosis but also signs and symptoms. This is particularly true when these signs and symptoms indicate a higher acuity than the discharge diagnosis.

Choosing the Correct E/M Code

The screening process may result in any one of the five emergency department Evaluation and Management (E/M) codes (99281-99285) and may require identification of diagnostic studies as well. Coders must recognize the payers definition of screening examination to determine individual payer considerations for coding.

Note: Payer definitions of screening are often considerably different than the EMTALA definition. Payers often choose to downcode when a screening exam does not indicate an emergency condition or when payment is not authorized prior to the ED visit. As a result, the lowest rate, often 99281 E/M service, is paid.

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 (e.g., office and other outpatient setting, emergency department, nursing facility, etc.). ED coders should review the CPT Evaluation and Management Services Guidelines section on Levels of E/M Services which establishes screening examinations as a component of each
E/M level.

The screening examination must be coded at the appropriate E/M level as determined by performance and documentation of the key components of the E/M service.

Managed Care Concerns

Managed care plans are notorious for denying payment for emergency services when, after the necessary screening, an emergency medical condition has been ruled out. But, EMTALA prohibits EDs from refusing screening to enrollees of managed care plans when the plan refuses authorization for treatment or refuses payment for screening and treatment.

Note: Regardless of whether a hospital will be paid by a managed care plan for screening, it must provide the service.

It is also not unusual for a managed care plan to retrospectively deny a preauthorized service if the final diagnosis determines that no emergency condition was present.

This again underscores the necessity for the coder to identify the signs, symptoms and conditions that the patient was experiencing which, as a result of the patients understanding of the problem, necessitated a visit to the ED.

Ensuring Necessary Documentation

And what about documentation? Physicians must provide detailed, legible documentation of ALL services regardless of whether or not an emergency medical condition exists. However, documentation is critically important when the patient must be transferred or, in many cases, the payer has not provided authorization for further treatment and the patient chooses to leave the department. Documentation must be consistent with the nature of the presenting problem, symptoms and complaint. There must be documentation of medically indicated screens, tests, mental status evaluations, impressions and diagnoses supported by adequate documentation of history and physical and test results. For patients with psychiatric symptoms, records must include assessment of suicide or homicide attempt or risk, disorientation, or assaultive behavior that indicates danger to self or others and the resolution of the problem(s) prior to discharge.

Most ED coding staff are aware of the existence of the AMA/HCFA Documentation Guidelines and its requirements for documentation as the foundation for coding. Physicians should also be reminded that appropriate documentation establishes appropriateness of treatment in compliance with EMTALA regulations. When documentation establishes that patients are appropriately managed, it protects the physician and the hospital from HCFA sanctions. Remember, especially to auditors, if it isnt written, it wasnt done!