ED Coding and Reimbursement Alert

Question: Does CMS have documentation guidelines for the facility level of ED service similar to those of the professional side?

Maryland Subscriber

Answer: Since the introduction of the OPPS concept at the turn of the century, CMS has declined to publish or endorse any guidelines for selecting the ED facility level. Facility coding guidelines are inherently different from professional coding guidelines. Facility coding reflects the volume and intensity of resources utilized by the facility to provide patient care, whereas professional codes are determined based on the complexity and intensity of provider’s work, including the cognitive effort expended in providing an E/M service or procedure. As a result, there is no definitive strong correlation between facility and professional coding and the assigned levels of facility service need to be determined on a case-by-case basis. 

The American College of Emergency Physicians along with the AHA, AHIMA and ENA developed a facility coding model for assigning visit levels in an Emergency Department. Unlike the point system models used by most software based products, this model uses clinical interventions and symptoms or examples which support the interventions as a proxy for the time and resources used by the facility not captured elsewhere.

This model is commonly known as the ACEP facility guidelines, which can be found at the following link:

https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/ED-Facility-Level-Coding-Guidelines/.