ED Coding and Reimbursement Alert

Nugget: Emergency departments will gain reimbursement for diagnostic services by coding signs and symptoms along with the final diagnosis. This new rule will help justify medical necessity.

Understanding the prudent layperson standard is crucial when working in an emergency room. Medicare and many insurance payers follow this federal law, which says that the patient determines the need for the visit. If the patient feels that his condition necessitates an emergency visit, then its an emergency, says Caral Edelberg, CPC, CCS-P, president of Medical Management Resources, a training and consulting firm in Jacksonville, Fla.

Although the law requires that facilities conduct whatever tests are necessary to either determine or rule out an emergency condition, neither Medicare nor private payers are obligated to reimburse for those tests, she explains. But a new rule, set forth on April 1, 2000, by the Cooperating Parties Group, which includes Heath Care Financing Administration (HCFA), and the American Hospital Association (AHA), instructs facility coders to use Field 76 of the UB-92 form to indicate the reason for the visit (chief complaint, signs and symptoms). As of that date, facilities are required to code the reason for the visit as manifested by the chief complaint, signs and symptoms on the UB-92 claim form along with the final diagnosis.

Since hospital coders have been told for years not to code signs and symptoms, most will be unfamiliar with the new methodology. In the past, they would have been penalized for coding symptoms, says Jack Turner, MD, of Team Health in Knoxville, Tenn., because coding signs and symptoms was not a facility service compliant with AHA guidelines.

This practice held true even if an insurance company indicated that it would pay based on signs and symptoms codes, Edelberg claims. Coders who follow the old guidelines can cause facilities some serious revenue loss.

The coding changes will be simple, because coders will use the same CPT and ICD-9 codes they currently employ. Most of the difference stems from the change in thinking required to override years of training. Its not a difficult thing to add these codes, but theyre going to have to think a little differently to do it, Edelberg said.

She hopes that as Medicare starts to use signs and symptoms for reimbursement, other carriers will look at Field 76 of the UB-92. Its just going to be a matter of wait and see.

Understanding the New Regulations

These new rules however, do not replace the AHAs outpatient coding guidelines that do not permit coding of signs and symptoms if a definitive diagnosis is confirmed. In most cases, if you go with a chronic or less acute diagnosis complaint, you may not meet the medical necessity requirement [...]