ED Coding and Reimbursement Alert

The abrupt change in coding after the implementation of APCs left many coders bewildered. In some cases, because both physician and facility coding are handled by the same department or coder, the best method for differentiating the two services lies in the documentation process.
 
APCs now require hospitals to establish and apply consistently an internal system for assigning codes and ensuring adequate documentation and medical necessity of services billed.
 
While some hospitals still code emergency services from the ED physician's documentation, those with coding guidelines specific to the facility side must adhere strictly to these rules. Barbara Steiner, RN, ART, ER coding coordinator for Northeast Medical Hospital in North Carolina, recommends following the ED physician's report to code for the professional component and following the nursing and ancillary staff's documentation to code for the facility services. Working off of two separate reports allows coders to distinguish precisely the staff services from the physician service. After coding for both services, Steiner says, compare the reports to verify consistency.

ED Physician Impacts Facility Reimbursement
Accurate ED physician documentation is important because it affects not only the professional component but the facility (technical) component as well. APCs now scrutinize physician utilization patterns in testing, treatment and resource consumption.
 
Under APC guidelines, hospitals must ensure the physician documentation supports the charges submitted by the facility. "Inconsistencies could raise red flags in the future," Steiner says. "A CMS audit of the facility will very likely lead to an audit of the physician.
 
"Because [facility-based] coders will be the control point of the billing process, they are going to be looking at much more physician documentation than they ever have in the past," Steiner says. And if the physician practice and hospital are commonly owned, all the bills must be consolidated into one. It is also important that the ED physician submit his or her documentation expeditiously, otherwise the entire billing process could be held up and neither the hospital nor the physician will be paid. "The impetus is to make sure that the hospital and office coding are in sync," Steiner says.
 
If a facility claim is filed before the physician documentation has been submitted, there is a chance for error. "If the facility's documentation doesn't list a procedure code recorded in the physician's documentation, this might flag the claim for possible review by Medicare," she says. Hospital administrators need to reinforce the importance of documentation from the physicians and educate the nursing and ancillary staff. "You don't want the coding to reflect what was supposed to be done, just what was done," Steiner says.
 
"You need to be sure that what the physician documents is what he does," says Kia Earp, CCS, coding specialists at Brigham and Women's [...]