ED Coding and Reimbursement Alert

by Andrea Clark, RRA, CCS, CPC-H

Editors note: The April issue of ED Coding Alert contained an article on the proposed prospective payment system for hospital outpatient services [also known as the Ambulatory Payment Classification (APC) system] and a related article on ED facility coding issues.

A primary source in both articles, Andrea Clark, RRA, CCS, CPC-H, a health care management consultant in Baltimore, MD, contacted us to extend some of her comments, which we had abbreviated for space reasons. In this column, we have provided her the opportunity to amplify her views.

Currently, there is speculation that Medicare will expect hospitals to use documentation guidelines and rules that physician coders do.

This may not be the case. Taking a cautious posture, Medicare does not give the facility enough information regarding the ER E/M code assignment beyond advising them to utilize the information in the CPT manual. Does this mean that the facility ER must utilize the components of history, exam, and medical decision-making just like their physician counterparts? At this time, it is very unclear. However, during the current comment period [on the proposed APC regulations], many organizations and facilities are expressing their displeasure with such an approach.

If the proposed regulation were effective today, there could be the potential risk of both higher or lower reimbursement. For example, a level 3 ER visit could be mistakenly reported as a level 2 ER visit or a level 4 could be mistakenly reported as a level 3 with the same diagnosis. Both of these examples will report entirely different APC hybrid codes, with different reimbursement attached. At this rate there is a potential for errors and compliance issues due to the variety of methods facilities use to assign and report ER levels of service.

In the meantime, health information professionals will certainly benefit by learning more about the components of professional E/M coding. The more we can learn about the physician side of coding and billing, the better prepared we will be not only for APCs but for the facility future coding and reimbursement needs.

I advise ER facility coders must prepare for the shift to APCs this way: The best offense is a good defense. To identify critical issues, the facilitys next steps should include a coding and billing audit of the facilitys ER. Accuracy and specificity of the ICD-9-CM diagnosis code(s), review of the ER chargemaster, and reliability of ER data transference to the UB92 claim form are the ABCs for preparing for APC reimbursement. Because only minimal guidance in ED E/M level designation has been provided by Medicare, before assigning levels of service based on facility documentation, it would be best to wait for the final APC regulations, which are due sometime before the end of 1999