ED Coding and Reimbursement Alert

Definitions and certifications are vital to code correctly in these venues.

Off-campus urgent and emergency care centers are popping up across the country, creating in their wake significant confusion for coders about which E/M code set to use in billing E/M services provided in these settings. To complicate things further, coders for freestanding EDs need to be aware of the rules governing whether or not a facility code can be charged for the visit in addition to a professional charge. Chart your path to compliant freestanding ED coding with these basics.

Added complexity: Both state and individual payer guidelines may govern how these facilities are designated and, thus, how services are billed. Medicare has its own requirements for how a freestanding "emergency center" can be designated as a true emergency department and urgent care centers are defined in a completely separate category with different coding requirements.

Get the Lowdown: Hospital-Owned Freestanding Emergency Care Centers

The term "freestanding emergency care center" (FECC) defines a facility that provides on demand emergency medical care in a setting that is geographically removed from a hospital. Such facilities may operate 24 hours per day or on a more limited schedule, and may or may not receive patients by ambulance. However, each must comply with state licensing and certification requirements which may vary from one state to another, says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates in Baton Rouge, LA.

CoP factor: Provider-based off-site hospital EDs must demonstrate compliance with the hospital Conditions of Participation (CoPs). They must also be in compliance with the provider-based regulations referenced at 42 CFR 413.65. In most cases, the freestanding ED will be owned and operated by a Medicare-participating hospital as a provider-based ED, Edelberg explains.

Most state and federal regulations dictate that free standing EDs be open 24 hours/day, 7 days/week though there are some exceptions.. The regulatory standards that govern whether or not provider-based EDs and so-called "emergency services hospitals" meet the CMS Condition of Participation determine how the freestanding ED qualifies for participation in Medicare.

All hospital-affiliated FECCs are regulated and licensed in the same way their parent facilities are regulated and licensed. Privately-held FECCs and urgent care centers are similarly regulated in many states with additional regulations aimed at the protection of the public from being misled by limiting the use of the terms "emergency" or "urgent" in facility names and/or promotional materials if all the requirements are not met, adds Edelberg.

According to the American College of Emergency Physicians (ACEP), hospital-owned FECCs are subject to all of the requirements of their parent's hospital-based ED, including 24-hour per day operation and EMTALA obligations. Both EMTALA and Medicare's Provider Conditions of Participation apply in full to these facilities.

E/M coding: Hospital-owned FECCs use the 9928X codes to bill E/M services for both the professional and facility charge. They are also required to differentiate between Type A and Type B emergency department facility services based on the hours the center is open and providing emergency services if they are recognized as an emergency department, says Edelberg.

Coding scenario: A 32 year-old male presents to a hospital owned FECC, that is open 16 hours a day and is formally licensed by the state as an ED, with moderate shortness of breath secondary to an asthma exacerbation. The emergency physician performs a detailed history and physical exam, orders several rounds of nebulizer treatments and a chest x-ray. The patient subsequently improves, the chest x-ray was read as negative and the patient is discharged to home, with a refill of his inhaler. Because this is a Type B ED, open less than 24 hours, the service would be reported using the ED E/M code 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; detailed examination; and medical decision making of moderate complexity.)

Check These Differences: Physician-Owned FECCs

In some states, individual physicians own and operate their own FECCs. According to ACEP, while hospital-owned FECCs are clearly entitled to utilize the 9928X Evaluation and Management CPT® code series for billing purposes, Medicare may prohibit their use outside the hospital-based ED setting.

Most physician-owned FECCs bill Medicare patients with office visit codes (99201-99215) in order to comply with Medicare requirements. In choosing this alternative, the new and established patient rules are in effect and add an additional "wrinkle" to billing for these emergency services.

Payer challenge: Most private payers oppose the use of the 9928X code series outside of the hospital ED setting but lack the legal authority of the government coupled with contracting and local market force issues- Both hospital and physician-owned FECCs typically charge a facility fee comparable to that charged in a hospital-based ED unlike less robustly resourced urgent care centers that utilize the physician office/outpatient clinic E/M codes (99201-99215).

Coding scenario: Consider the same new patient as above who presents to a physician owned FECC that is not licensed by the state nor recognized as a formal emergency department. In this scenario, you would report the service using the office or other outpatient E/M code. In this case 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; detailed examination; and medical decision making of low complexity) because the history and physical exam requirements are different for this code set, and the level 4 service 99204 requires a comprehensive history and physical exam to be documented.