ED Coding and Reimbursement Alert

Question: The company that manages our ED has opened a freestanding emergency department and asked me to handle the coding for it. Is the coding the same as it would be in a regular ED or different?Codify Subscriber

Answer: The term "freestanding emergency department" (FSED) defines a facility that provides on-demand emergency medical care in a setting that is geographically removed from a hospital but is still open 24 hours per day, seven days a week.

Both state and individual payer guidelines may govern how these facilities are designated and, thus, how services are billed. Medicare has its own requirements for how a freestanding "emergency center" can be designated as a true emergency department and urgent care centers are defined in a completely separate category with different coding requirements.

There are two common types of freestanding EDs and the rules may be different depending on the type for which you are coding.  

The first consideration is whether the facility is a hospital outpatient department (HOPD), considered an extension of the main hospital campus or system, or whether it is a Free Standing Emergency Center (FSEC), meaning it is privately owned and not affiliated with a particular hospital. The FSEC may have arrangements for transfers, admissions and access to the medical staff of a nearby facility.

Some physician-owned FSECs bill Medicare patients with office visit codes (99201-99215) in order to comply with Medicare requirements. In choosing this alternative, the new and established patient rules are in effect and add an additional "wrinkle" to billing for these emergency services.

Payer challenge: Most private payers oppose the use of the 9928X code series outside of the hospital ED setting, but lack the legal authority of the government, coupled with contracting and local market force issues. Both hospital and physician-owned FSECs typically charge a facility fee comparable to that charged in a hospital-based ED, unlike less robustly resourced urgent care centers that utilize the physician office/outpatient clinic E/M codes (99201-99215).

Therefore, you should check with your payers, as well as your state licensing boards, about what the coding and billing rules are in your area for freestanding EDs vs. those located in hospitals to ensure that you're coding properly.