ED Coding and Reimbursement Alert

Getting the facility payments right will help you keep your job there.

CMS continues to have no official methodology for determining ED facility levels, but if you know where to look, there are some guidelines available for crafting your own. Read on to learn the source of CMS' guidance and tips on how to apply it to your practice.

Basics: There are two components to consider when reviewing ED cases for reimbursement; the professional component for physician services and the facility component for other services which includes nursing and ancillary services. The CMS Outpatient Prospective Payment System (OPPS) gives hospitals direction for reporting facility services using the CPT® E/M codes. At this time, there are no national guidelines for the assignment of the E/M codes for outpatient facility services in the ED.   

According to the FY 2015 OPPS final rule, hospitals are to continue to follow the directions published in the FY 2008 OPPS final rule, says Sarah Todt, RN, CPC, CPMA, CEDC, Director of Provider Education and Audit for LogixHealth in Bedford, MA. 

In the absence of national guidelines, hospitals are required to establish their own set of guidelines based on the following 11 elements defined in the 2008 final rule, which stipulates that the coding guidelines should:

1. Follow the intent of the CPT® code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.

2. Be based on hospital facility resources. 

3. Be clear to facilitate accurate payments and be usable for compliance purposes and audits.

4. Meet the HIPAA requirements.

5. Only require documentation that is clinically necessary for patient care.

6. Not facilitate upcoding or gaming.

7. Be written.

8. Be applied consistently across patients in the clinic or emergency department to which they apply.

9. Not change with great frequency.

10. Be readily available for fiscal intermediary (or, if applicable, MAC) review.

11. Result in coding decisions that could be verified by other hospital staff, as well as outside sources.

Don't Assume Facility and Professional Guidelines Are the Same

The facility guidelines are inherently different from the guidelines for professional services, say Todt. As seen in  the 11 guidelines above, hospitals may develop and utilize their own unique system.  The guidelines should, per OPPS, "relate the intensity of hospital resources to the different levels of effort represented by the code." This would indicate that lower intensity services should result in a lower level of service, while higher intensity services should result in a higher level of service. 

When adapting hospital guidelines, they should relate only to hospital facility resources, not physician resources, says Todt. There is no expectation of a complete match to the professional Evaluation and Management code assignment; however, it would stand to reason that there would be some similarities in the distribution, she clarifies.  

Make Sure You Also Document Medical Necessity

The guidelines require documentation that is clinically necessary for patient care and should not cause upcoding, Todt adds. Guidelines should not require unnecessary documentation or cause staff to document extra items in order to increase the level of service. 

An example of this would be a documentation policy that requires three sets of vital signs for every patient regardless of the complaint and a facility guideline that scores all patients with three or more sets of vital signs at a 99284 or higher. This practice would have the appearance of gaming or upcoding, since three sets of vital signs is not always clinically necessary, Todt warns.

Put Your Facility Guidelines In Writing

The hospital's unique guidelines should be a formal written document which is easily understood so that it can be applied consistently across all cases, says Todt. For example, an auditor using the guidelines should be able to obtain the same results as the coder. The guidelines should remain in place without frequent modifications. When the guidelines are changed frequently, it becomes more difficult to apply them consistently. 

In the event of an audit, the hospital facility guidelines should be made available for review and verification of code selection. These guidelines should also be available for Medicare Administrative Contractor (MAC) reviews, she adds. Keep in mind a previous version may have been utilized so keep these on file in the event of an audit.

Consider These Options When Choosing A Mapping Methodology That Works Best For Your Hospital 

Be aware that there are many types of facility guidelines available for use and no single guideline has been identified as the official CMS methodology, Todt says.  

Examples of the guideline models currently in use include; point systems, intervention based models, time based models, and clinical severity scores. 

Point based systems may be Electronic Medical Record driven or calculated from a chart review. Intervention based models evaluate interventions which represent a proxy to the intensity of services provided.  

Questions have been raised about the proxy model's including billable services as interventions.  CMS instructs:  "In the absence of national visit guidelines, hospitals have the flexibility to determine whether or not to include separately payable services as a proxy to measure hospital resource use that is not associated with those separately payable services. The costs of hospital resource use associated with those separately payable services would be paid through separate OPPS payment for the other services", Todt adds. 

Bottom line: Hospitals have some flexibility in creating their own set of facility guidelines. The eleven elements should be reviewed to ensure the guidelines are appropriate. Analysis of coding, auditing and distributions should help verify the appropriateness of the guidelines. Hospitals should review the OPPS final rule annually to be aware of changes remain compliant, says Todt.