ED Coding and Reimbursement Alert

Question: How should I code E/M levels for a facility? Do most facilities use the same HCFA guidelines that apply to the professional fee?

Rich Sobieray
Blue & Company, Indianapolis

Answer: HCFA has instructed that each facility may set its own guidelines for determining the facility E/M for ED visits, as long as the levels are tiered to reflect acuity and resources. Very few facilities have used the professional-component physician documentation guidelines to establish nursing criteria because those guidelines do not accurately reflect the resources required by the facility to provide ED care.

There is no expectation that the physician E/M and the facility E/M should match. Facilities should develop nursing criteria that are useful and objective criteria in assigning the level of care. In general, criteria should not be so complicated that it cannot be managed easily.

Some facilities use a scoring system in which the ED staff designates a point value to each item applicable to the patient visit and services rendered. A range of points defines each level, and the visit level is determined by the total of points related to the services provided.

Point systems can be somewhat cumbersome, however. HCFA and the AMA have developed a scoring system to support their documentation guidelines (guidelines are available from both HCFA and the AMA), but it has met with much criticism because its use and interpretation have not been uniform. The lack of uniformity has caused many controversies among providers and payers. As a result, the new documentation guidelines under development at this time do not use a scoring system.

The alternative is to designate each level based on the content of service, with a minimum content for each level. Such a system can be developed by comparing patient presentations and the intensity of care provided for each. Patients should fall into discernable levels based on resource intensity required. Experienced staff can help you determine what level of care a certain patient falls. Other resources, including CPT vignettes in the ED E/M section of the CPT manual, may aid development of a such a system.

Some hospitals require coders to assign E/M levels, while others rely on the nursing staff. Either way, a uniform system will lead to increased consistency and more accurate assignment of levels of care.