ED Coding and Reimbursement Alert

Payment levels also increase in 2014 OPPS final rule.

For now, you can expect the status quo for the ED facility level codes, with the added bonus of dramatic payment rate increases in the coming year.

Vital: The issue of greatest concern to ED providers from the OPPS proposed rule was over the suggestion to reduce the number of facility ED levels from the current 5 to only 1, paying about $250 no matter what level of service was provided, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, an ED coding and billing company in Bedford, MA.

Big bonus: “Fortunately, CMS has decided to continue to reimburse hospitals for ED visits based on 5 levels of ED service plus critical care,” says Granovsky. “This is a huge win for emergency medicine because not only are the five levels better able to allocate true facility costs associated with the level of care provided, the 2014 payments for those levels actually increased.

CMS did flatten the outpatient clinic services, reported with CPT® codes 99201-99215, to one payment, replacing the current five levels of visit codes for each clinic visit with a new alphanumeric Level II HCPCS code G0463 representing a single level of payment for outpatient clinic visits, Granovsky explains.

“HCPCS code G0463 now maps to a newly created APC 0634, with 2014 OPPS payment rate of $92.53 based on the total mean costs of Level 1 through Level 5 clinic visit codes obtained from 2012 OPPS claims data. This payment would apply to facility based outpatient clinics and the facility component of provider based urgent care centers in 2014,” Granovsky adds.

ED Facility Levels Stay At Five, But Facility Clinic Visits Do Not

Here’s why: CMS explained the reason for collapsing outpatient clinic levels but not ED levels because it believes that the spectrum of hospital resources provided during an outpatient hospital clinic visit is appropriately captured and reflected in the single level payment for clinic visits. Therefore, CMS believes that a single visit code is consistent with a prospective payment system, where payment is based on an average estimated relative cost for the service, although the cost of individual cases may be more or less costly than the average.

Now the math part: CMS did not find wide disparity among the estimated geometric mean costs for new or established clinic visits and goes on to say that there is significantly less disparity in estimated geometric mean costs among the current five clinic visit levels than there is among the five ED visit levels, Granovsky explains.