ED Coding and Reimbursement Alert

Most hospitals are getting used to the idea of fee-schedule reimbursement for outpatient services, but few are prepared for the imposition of line-item coding on Jan. 1, 2001, according to Caral Edelberg, CPC, CCS-P, president of Medical Management Resources, an emergency department coding consulting firm in Jacksonville, Fla. Although hospitals can bundle now-itemized procedure charges, that loophole ends in a few months and facility revenue will be threatened.

How will this affect emergency department (ED) coders? First, they will have to draw on more documentation to assign visit codes. Second, they must learn and use a host of CPT and ICD-9 codes they never had to use before. Third, they will have to learn how to use the ambulatory payment classifications (APC) rules to ensure appropriate revenue for the hospital.

The ED is unlike any other department in the hospital in that every patient is new and nobody has an appointment. Those differences make the ED particularly vulnerable to the effects of APCs, which affect all facility outpatient coding and billing. In fact, at most hospitals, the emergency department will be the hardest hit by the new Medicare outpatient prospective payment system (OPPS).

APCs will require EDs to make a lot of organizational changes, and coders will not be immune from the effects. But theres no need to panic. Coders just need to use a little extra caution and become familiar with the new rules, and they can help smooth the transition to APCs.

Most hospitals APC teams contain at least one representative from the coding department and at least one from the ED clinical staff, so the people who will be hardest hit by these changes will be taken into account during the planning.

In the past, many EDs simply mirrored physician coding and never set up criteria for visit levels, says Kelly Kracher, manager of oncology services at the Nebraska Health System in Omaha. Some hospitals mirrored and some will choose to continue to mirror. You just have to create a system thats consistent.

For many hospitals, a consistent system will revolve around nursing documentation, she says. Because some facilities currently require minimal documentation from nurses, the additional documentation will add complexity to the job of the coder.

This new emphasis on nursing documentation will help EDs better capture the resources being used. Sometimes the physician comes in and spends 10 minutes with the patient, but the nurse could spend more than an hour discussing everything from disease etiology to medication management to family counseling, Kracher says. Nurses also may be required to keep track of supplies and other often-unrecorded matters.

In addition to physician and nursing documentation, Kracher says that ED coders will have to use data from lab results, internal and external records, and radiology charts. APCs affect every outpatient ED case, and every test requested by an emergency physician for an outpatient case will be coded and billed under APCs. That information was not documented on the facility side before. Now it is, she adds.


Visit Levels

Each facility must develop its own criteria for visit codes (99281-99285), and coders must learn what their employers require. Kracher developed a system that weights the visit equally according to four criteria:

1. Presenting problem;
2. Time spent with the patient;
3. Collection and coordination of data with the patient;
4. Resources used.

Each ED will use a different system and, in many cases, the clinical staff may set the visit level. But its up to the coder to sift through the documentation and determine a visit level or verify that the one already assigned is justified.

Procedure Codes

Outpatient procedure codes will become more important under APCs, Edelberg says. For a significant number of your patients, youre going to be entitled to both procedure and visit reimbursements.

Although APCs will bundle most ED supplies and medications into visit codes, they do allow charges for multiple procedures in addition to the visit level. Unfortunately, few facilities have hard data on numbers and costs of procedures performed in the past, simply because they would bundle such services as treatments of lacerations or intramuscular injections under one larger charge.

Under APCs, each 2.5-centimeter laceration repair (12001*), IV injection (90784) and shoulder fracture manipulation (23675) must be coded under an APC for that category (024, 359 and 044 respectively).

Revenue Generation

Although many ED coders were isolated from the billing process in the past, APCs are likely to involve them because only someone looking at the chart in detail can find all the potential sources of revenue. This is especially true in the ED setting, when coding is often done in a different department, and perhaps during an entirely different shift, than the place and time of treatment.

Despite the lack of hard data on APCs financial impact, coders can take some proactive steps to preserve the hospitals revenue stream, and thus make themselves more valuable under the new system.

1. Make sure you capture all of the information. Check for overlooked revenue generators such as injections or pass-through medications that arent bundled. Code every single service, procedure and supply you can find, then check to see whether theyre allowable under APCs, Edelberg says. Many hospitals are letting Medicare decide what gets paid by just billing everything until the system shakes out.

2. Find alternative revenue streams. If a doctor prescribes 3 mgs of Demerol for pain, the hospital wont be reimbursed for the medication. But if the patient requires three injections, the facility can bill 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) three times. That code falls under APC 359, which includes both intramuscular and intravenous injections and has a base reimbursement of $46.55.

3. Make sure that youre clear on which modifiers will be used. Review instructions for using modifiers at the HCFA Web site, your fiscal intermediarys Web site, and through national coding organizations. Many hospitals havent used them, even though theyve been required for a while, Edelberg says. Most cant be hard-coded via the charge master, so coders will have to assign most of them.

In addition to the HCFA training manual, review the actual APC regulations themselves at www.hcfa.gov/ regs/hopps/default.htm for detailed information.