ED Coding and Reimbursement Alert

Although they are coding for the same ED visits, hospital information coders and emergency physician practice coders rarely speak the same language when it comes to reporting the procedures and services delivered.

“Hospital coding and physician coding are two separate worlds,” states Charlene Day, BS, CMA, CMM, practice manager for Team Physicians of Arizona, an emergency medicine practice group in Phoenix, AZ. “It is often very confusing for a hospital coder and a physician coder to even discuss coding, and it’s nearly impossible for health plans to understand the concept—something I am dealing with now.”

But, with Medicare shifting hospital reimbursement for ED services into one lump sum payment and managed care demanding more cost accountability for all emergency services, ED professional coders and facility coders will have to work together if the hospital and emergency physician group expect to survive.

Why Should You Care?

Unlike other specialties, emergency medicine often blurs the line between inpatient (hospital) and outpatient (often thought of as office-based) services. The ED physicians work at the hospital but are not hospital employees. They may bill for their services separately. They are not reimbursed for services provided by the nurses, who are employed by the hospital, and they do not bill for supplies, as these are provided by the facility as well.

When reporting ED services, the hospital seeks reimbursement for use of the actual facility—the space in the emergency department—used by the physician, the supplies used, and the services delivered by the hospital employees.

In the past, the facility side of ED coding and professional side rarely interfaced, says Day. The physician group billed third-party payers for its services; the insurance plans reimbursed the hospital a percentage of its charges in a separate payment. However, in recent years, third-party payers, particularly managed care, have begun to scrutinize the cost of ED services. Many of them do not want to receive two bills for the same visit and expect the physician group to add its charges to the hospital bill, says Day. And, she indicates, many health plan representatives don’t understand the difference between facility and professional ED coding. They will often question ED professional coders about any differences reported by the hospital information department, and vice versa.

Facility Coding vs. Professional Coding:
What’s the Difference?

1. Professional coders must follow CPT. When a patient presents to the ED for care, emergency physicians must follow strict rules for documenting and coding their evaluation and management (E/M) services and any procedures they perform.

“Physicians are mandated to use the Health Care Financing Administration (HCFA) guidelines along with CPT-4 to code their records,” says Day. CPT and HCFA have set rules detailing which services warrant a particular level of code and, therefore, the amount of payment the physician will receive. Each code has a set relative value unit (RVU), which corresponds to a dollar amount in Medicare’s (or other third-party payer’s) fee schedule. These codes are reported to Medicare, and usually to other payers as well, on the HCFA-1500 form, although some private payers require the professional codes to be a line item on the hospital’s UB92.

2. Facility coding requirements are not the same.This system is quite different. Currently, most hospitals are reimbursed for outpatient services by receiving a percentage of the charges that they report. Hospitals report their facility charges to third-party payers on the UB92 form and use the “nursing level of acuity” as a guide for determining the level of service to report, says Day.

Hospitals have the option under the Hospital Medical Manual to report this level of service using CPT office/ outpatient codes (99211-99214) or they may just use CPT code 99201 (office or other outpatient visit, new patient) for every visit, she states.

“Normally, the hospital bills the nursing level of acuity, which for most hospitals is levels 1-4,” Day says. “But, the hospital does not actually have to differentiate between levels. They could use a level 1 for all visits, then just itemize everything (nursing services, room charges, registration, etc.) under that level of service.”

The Medicare hospital manual states in section 442.7 (effective Oct. 16, 1991): “Use code 99201 to report a visit in a hospital OP (outpatient) department . . . Use code 99201 for new patients and 99211 for established patients regardless of the duration or complexity of the visit . . . Report codes 99202-99215, 99281-99288, or 92002-92014 in lieu of 99201 if you wish, but this level of detail is not required. [emphasis added].”

Because hospitals are currently reimbursed for ED services on a percentage-of-charge basis, it should only matter what charges they report and how they document them, not the actual code applied.

3. E/M coding is becoming more important for hospital coders. However, this will change with the implementation of the proposed outpatient prospective payment system Ambulatory Payment Classifications (APCs). (See special insert in this issue.)

Medicare is proposing a five-digit hybrid code for facility coders which will include both the facility’s ED E/M level of service and the principle ICD-9-diagnosis code, advises Andrea Clark, RRA, CCS, CPC-H, a health care management consultant in Baltimore, MD, who frequently works with hospital information departments on coding, compliance, and reimbursement issues. This proposed hybrid code places an importance on the facility’s choice of ER E/M level; which was never an issue before.

“Basically, as long as the E/M level of service transferred to the UB92 claim form, the requirement was met.

The different regulations regarding coding also present problems with some third-party payers who wonder why the hospital claim for services and the emergency physician’s claim frequently don’t have the same level of service indicated.

“Once in a while we have to touch base with the hospital coders because the health plans get two different codes, sometimes different CPT and ICD-9 codes, and they want them to match up,” adds Day. “The health plan tells the patient to call the hospital, which tells the patient to call the physicians and tell the physicians that the codes have to match. By the time the message gets to us, the patient is requesting a change in diagnosis or some other code so that the plan will pay. Obviously that is illegal and fraudulent, which we explain to the patient. But, then they insist that this is what the hospital and plan said needs to happen before it will pay.”

What To Do

How should these conflicts be resolved? First, says Clark, the hospital information personnel need to require their coders to adhere to CPT-4 guidelines for reporting E/M services.

Second, they must begin accurately reporting all procedures performed in the ED, including those performed by physicians.

According to Medicare guidelines since 1987, Clark says, outpatient departments—including the ED—should also be reporting these procedure codes on the UB92 claim form.

“There has been a misunderstanding that the hospital should not be picking up the procedures in the range of 10000 through 69999 because the facility doesn’t charge for the procedure,” she explains. “But, when you get down to it, how is the hospital supposed to get paid the charges for the room, unless the procedure performed there is indicated?”

Hospital coders, in many cases, are reporting the ICD-9 codes for medical necessity and the ICD-9 procedure codes (which Medicare does not recognize in the outpatient setting) but not reporting the CPT procedure codes, she adds.

Hospital information professionals who code for the ED should be re-educated to realized that these physician procedures should be included on the UB92 claim form, even though the facility is not receiving reimbursement for the procedures.

“There are charges on the facility bill for the room and the claim form needs the procedure codes to justify why those charges are there,” Clark emphasizes. “The hospital is not expecting to get paid for the service the physician performed, the hospital is charging for the cost of the room and the nurses and registration.”

The Medicare guidelines, revised in 1987, specifically allowed outpatient departments to pick up CPT codes in the range of 10040-69979 to justify their charges, Clark contends.

“Most hospitals did do that for ambulatory surgery and other sites, but they are not reporting these procedures in the ED.”

In addition, emergency physician professional coders and facility coders must devise some way to communicate about how each is billing for their services, she adds.

For example, the hospital information department might request a copy of the professional staff claims, then designate a staff member to compare the claims with the codes reported by the hospital. That staff member could also contact the billing company to resolve any discrepancies.

Warning for Departments that Code both
Facility and Professional Services

Clark sees other problems in hospitals where the hospital information department codes both the facility ED charges and the physician charges.

In some cases, a procedure performed by a nurse or other hospital staff member should be coded on the UB92, but not on the physician’s HCFA-1500, she says.

“If you are coding for facility charges, it doesn’t matter whether the ED physician, the nurse, or, for example, an orthopedic surgeon on a consult, performs a procedure. For the hospital, they code to reflect the facility charges,” Clark explains. “But, you have two sets of billing guidelines. The procedure should only be reported on the HCFA-1500 of the ED physician if that physician actually performed the procedure.

Sometimes, I have seen systems that put these codes [for procedures performed by a nurse or other physician] on the physician’s bill, which is fraudulent.”

Clark recommends separating the task of coding for the ED physicians from coding for the remainder of ED services, even though the reporting of the services must be coordinated.

Coders should report the physician portion of the services separately. Then, the department should have another staff member code the facility portion—not do the two together.

Resolve ICD-9 Coding Conflicts

Another major source of friction between professional coders and facility coders in the ED, is the concept of diagnosis coding for medical necessity, say both Clark and Day.

Hospital-based coders, often trained to code inpatient services, often feel that they can only report an established diagnosis, not vague signs and symptoms.

Professional-side coders for emergency services are accustomed to reporting ICD-9 codes for signs and symptoms if that was the information available to the physician and prompted the physician to perform a certain treatment or order certain tests.

“A patient presents to the department with chest pain, what is the first thing that he is normally worked up for?” asks Clark. “An MI (myocardial infarction). So, the physician orders an EKG and other tests that determine it isn’t an MI, but just gastritis. If you don’t put the ICD-9 code for chest pain down along with the code for gastritis, the EKG is not paid for because gastritis is not a justifiable medical reason for ordering an EKG.”

However, the physician had no way of knowing the patient was not suffering an MI when the test was ordered.

“I tell hospital coders, report the gastritis, yes, but report the chest pain as well,” Clark says. Hospital coders should be aware that it is acceptable in outpatient coding to code the signs and symptoms if these indicate the “real” reason the patient presented to the ED.