ED Coding and Reimbursement Alert

You’ll need to stay on guard.

Billing ED visits may seem simple at first glance, but recent CMS data indicates that for Part B providers, it may be more complex than you think.

Here’s why: Several Medicare Administrative Contractors (MACs) have listed CPT^® codes 99281-99285 (Emergency department visit for the evaluation and management of a patient …) on their Targeted Probe and Educate (TPE) active review lists.

What that means: TPE is a Medicare claims review process performed exclusively by the MACs. TPE targets at-risk providers and consists of three rounds of review, in which 20 to 40 claims per round are selected for an audit. The MACs decide how many claims a practice must furnish and when to send them.

Practices are alerted by letter; however, audit start dates and providers’ end dates for TPE rounds will vary due to when they receive this letter.

Timeline: The MACs allow 45 days to respond to the TPE notification, which gives you time to gather your medical record documentation that supports the services you plan to bill.

Register These ED Codes’ TPE Stats

Several MACs have announced their TPE plans — for instance, Part B payer WPS Medicare published its TPE process on June 25. “Before you send the requested records, WPS GHA suggests a clinician double-check the accuracy of your submitted claim,” the MAC says in its TPE announcement.

That’s because you want to make sure you have everything in the documentation that will support the ED E/M code level you reported. Documentation of a complete claim within the 99281-99285 range will include the following, WPS notes:

• An ED visit note
• Lab testing ordered or reviewed
• Radiology tests ordered or reviewed
• Other services from CPT^®’s medicine section
• Documentation of medications administered in the ED
• An attestation statement if the physician’s signature on the note is illegible, stamped, or missing.

The reason this is so important is that during the TPE review staff from your Part B payer will review the medical record, verify timely receipt of it, determine payment, and evaluate whether any overpayments are due.

See How This Payer Evaluates E/M Accuracy

The various insurers may have different internal processes to evaluate whether to pay ED claims, but in general, they tend to follow similar criteria. UnitedHealthcare (UHC), a private payer, for example, uses its own nongovernmental process, a claims analyzer that applies an algorithm to your claim to determine the ED visit level. That algorithm considers the following three factors in its calculation:

• The presenting problems, based on the ICD-10 code assigned as the reason for the visit
• Diagnostic services performed, such as X-rays, lab tests, EKGs, MRIs, ultrasounds, or other services
• Patient complexity and comorbidity, based on compli­cating conditions or circumstances, based on ICD-10 principal, secondary, and external cause of injury codes.

Did the third bullet stand out to you? Readers may be surprised to see that third bullet point, since some ED coders simply rush through assigning ICD-10 codes, and sometimes just put one diagnosis code on the claim to save time. However, UHC’s guidelines make it clear that those tertiary diagnoses are essential in calculating the E/M level.

Of particular note is UHC’s mention of “external cause of injury” diagnosis codes. There are some coders who say they typically skip these diagnoses, but to see in black and white that they add to the complexity/comorbidity of the claim makes it clear that they are just as important as the primary diagnoses.

Here’s what they are: Correct coding requires you to report these codes, which describe the causes of injuries, diseases, and other issues. These codes are part of the ICD-10-CM system, which instructs you to code an encounter to the highest specificity possible.

Coding example: A 5-year-old girl falls from the jungle gym on the school playground and suffers a 2.0-cm cut on her right eyelid. The emergency department physician performs a simple repair.

You should report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) linked to a primary diagnosis of S01.111 (Laceration without foreign body of right eyelid and periocular area) and a supplementary diagnosis of W09.2XXA (Fall on or from jungle gym, initial encounter) in this situation.

Resource: To read more about WPS Medicare’s TPE related to ED visits, visit www.wpsgha.com/wps/portal/mac/site/claim-review/news-and-updates/cpt-codes-99281-99285-emergency-dept-visits/.