ED Coding and Reimbursement Alert

Documenting timed services, reporting observation care factor into your audit-busting tactics.
If you are new to facility coding, it can seem like a whole new world. However these professional side coding tips can transfer to assignment of your facility level choice as well.
Contributing to the complexity of managing the coding and billing for the technical (facility) component of an ED visit are a number of factors, including the difference in rules governing how services are described within the same code set, says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates in Baton Rouge, LA.
1. Focus on clinical staff documentation.
Before implementation of the Outpatient Prospective Payment System (OPPS), the primary focus was on physician documentation with less emphasis placed on nursing documentation habits, but that has changed. Now it is important for clinical staff, particularly nursing staff, to understand the hospital's coding requirements to assure that documentation meets compliance standards.
Crucial: Timed services such as observation, critical care, infusions and injections require start and stop times to assure they are being reported correctly, says Edelberg. E/M levels must be billed consistent with the guidelines and descriptors established by the individual facility which demands that ED clinical thoroughly document all assessments, interventions, treatments, ED course and the patient's response to treatment, she adds.
CMS published general standards for ED E/M facility coding to provide some guidance since hospitals have been given the opportunity to uniquely define the ED levels of service for each facility. Hospitals must assure the levels were reported in an appropriate manner and that each facility's internal guidelines are consistent with the required 11 elements. (Editor's note, see the list in the April 2012 issue, Vol. 15, no. 4)
2. Look to CPT® code descriptors for guidance.
There are still no national CMS facility coding guidelines, but CPT® can serve as a resource.
CMS has advised hospitals that each hospital's internal guidelines that determine the levels of clinic and ED visits should be reported by following the intent of the CPT® code descriptors, says Edelberg. In other words, design your guidelines to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes.
Although much effort and focus has been placed on the development of a nationally uniform emergency medicine facility coding criteria, to date CMS has not adopted any one set of criteria. The American College of Emergency Physicians publishes what is considered the most frequently used ED facility criteria on its website, www.acep.org, says Edelberg.
Service providers: Unless indicated otherwise, CMS has not specified the type of hospital staff (for example, nurses or pharmacists) who may provide services in hospitals because the OPPS only makes payments for services provided "incident to" physicians' services, she adds.
Triage or LWBS patients: However, in answer to the question, "Can hospitals bill Medicare for the lowest level ER visit for patients who check into the ER and are "triaged" through a limited evaluation by a nurse but leave the ER before seeing a physician?" CMS responded, "No. The limited service provided to such patients is not within a Medicare benefit category because it is not provided incident to a physician's service. Hospital outpatient therapeutic services and supplies (including visits) must be furnished incident to a physician's service and under the order of a physician or other practitioner practicing within the extent of the Act, the Code of Federal Regulations, and State law. Therapeutic services provided by a nurse in response to a standing order do not satisfy this requirement."
Reverse decision: This recent clarification reversed previous advice from CMS that permitted triage fees to be billed, Edelberg explains.
3. Identify additional facility services that can be reported separately from the facility visit level.
One significant area of controversy is how E/M services may be defined and what additional services should be included in the E/M level. Many hospitals voice concern over any reference to surgical procedures in E/M levels as these are billed separately, says Edelberg.
However, CMS has stated repeatedly that separately payable services, such as hydration or infusion, could serve as a proxy for the resources that the patient will consume and that should be attributable to the hospital visit. This is perhaps the most controversial area of confusion for hospitals, says Edelberg. In such cases, consideration of separately payable services in reporting visit levels does not result in double payment for components of those separately payable services. CMS has continued to express a belief that a patient with high medical acuity will consume more hospital resources in the visit than a patient with moderate acuity. In addition, CMS has stated that there are advantages to including separately payable interventions in the facility E/M guidelines as examples, because a measure of acuity may be lost in the absence of recognition of these procedures and stated that it was in agreement with the American Hospital Association (AHA) and AHIMA (American Health Information and Management Association) that it might be easier to distinguish among five levels of coding if separately payable interventions are included as examples, she adds.
The bottom line: To date, there has been no change in facility E/M coding requirements for the ED nor have there been significant audits on ED facility E/M levels. However, medical necessity determination for levels of service has been on the CMS and audit radar and will continue to require vigilant watching by providers to make sure whatever mapping methodology they choose accurately reflects resources required to treat the presenting condition, Edelberg advises.
4. Your professional and facility service levels don't have to match.
If you're grappling with a disparity between facility ED levels not matching professional E/M levels, no need to worry.
Each identifies separate services -- most commonly the ED physician level only defines the resources provided by that individual physician. However, facility resources include the services of all staff as well as resources used to support other physician consultants who perform services in the ED with assistance of the ED staff, clarifies Edelberg.
The same goes for surgical procedures. Those not performed by the ED physician won't be billed as professional services by the emergency physician. However, the facility will bill for the resources used to support consultant services, such as orthopedic stabilizations performed by orthopedists.
An additional high focus documentation area for facility billing is accurate reporting of infusions and injections which account for a large number of services provided by ED nursing staff.
5. Count face-to-face, bedside time for critical care.
For the emergency physician to bill critical care, a time based code, the content of the service reported rests solely on the emergency physician or non-physician practitioner. Thus, the time spent in management of the critically ill or injured patient reported does not require face-to-face time with the patient, says Edelberg.
Facility factor: For facility billing purposes, you will report the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient.
When the physician and hospital staff are simultaneously engaged in providing bedside critical care, the time involved can only be counted once. Managing the documentation of individual time at the bedside by the number of clinical staff has proved to be a difficult process for many hospitals. Without accurate reporting this will become another audit risk for hospitals, adds Edelberg.
6. Don't overlook observation services.
Correct reporting of additional services for observation patients presents some challenges for coding when other services occur during the timed observation care. According to CMS, observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure, Edelberg explains.
Rule to follow: In situations where another procedure requiring monitoring is provided during the time of observation services, such as colonoscopy or chemotherapy, and results in two or more distinct periods of observation services, hospitals should record for each period of observation services the beginning and ending times during the hospital outpatient encounter, says Edelberg.
Do this: Hospitals should add the lengths of time for the periods of observation services together to determine the total number of units reported on the claim for the hourly observation services under HCPCS Code G0378 (Hospital observation service, per hour). For example if a patient is admitted observation status on Friday evening and discharged on Saturday morning, you would report the total hours spent providing observation, even though that is captured by two codes on the professional side.
Caveat: Nursing staff will need to be extremely cautious when documenting time spent on these additional services during the observation period. If the hospital determines that active monitoring is part of a drug administration service (such as blood transfusions) furnished to a particular patient and separately reported, then observation services should not be reported with HCPCS G0378 for that portion of the drug administration time when active monitoring is provided, warns Edelberg.