ED Coding and Reimbursement Alert

Use This Check List to Make Sure You Are In Compliance

Before embarking on developing coding policies for a freestanding emergency center, (FECC), you must first determine the following, advises Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates in Baton Rouge, LA.

• Who owns the center? If a physician, has it been certified by the state AND Medicare as a stand-alone FECC and "bonafide" emergency department? If owned by a hospital, does it meet provider based ED requirements? Does it have its own provider agreement and is it open 24/7?
• Has the center qualified as a FECC through the state certification requirements by meeting all emergency provisions? If so it will be required to EMTALA standards and provide medical screening exams in addition to a long list of requirements for licensing and certification.
• Has the facility been approved as a provider by Medicare? Typically, physician owned urgent care centers and freestanding EDs only bill for the professional fees while freestanding EDs and urgent care centers/clinics owned by the hospital bill for both professional and facility charges. However, there may be exceptions, and you will need to clarify how the center is certified and approved to assure you are billing correctly.
• Is the FECC open 24/7 or does it have restricted hours? If hospital owned and open less than 24 hours, the Type A/Type B distinction will be necessary for Medicare patients. If physician owned and open less than 24 hours you will need to determine whether or not you may use the ED visit codes for Medicare. Typically you will use the clinic/physician office codes.
• Will the certification allow you to bill a facility fee in addition to the professional fee? If so, you will bill the 9928X ED E/M codes for both professional and facility or, if not, the 9920X/9921X New and Established clinic/physician office codes for outpatient clinic/physician office services.