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 Hospital in Boston. "If there is any difference in the complexity of the procedure, the physician must state it in his dictation."

APCs may not directly affect ED physician reimbursement, but they have a big impact on hospital billing and reimbursement of outpatient services. Therefore, it is important for ED physicians to work constructively with the hospital to ensure that the interpretation of APC rules will not harm them.
 
Either physician or nursing documentation must support medical necessity and record the delivery of the services. It is important to involve the ED nurse administrator because proper coding may rely on the nurse's documentation to fill in gaps that may appear in an ED physician's notes. Because APCs incorporate CPT into its payment system, the nursing level of service must conform with this methodology.
 
For instance, if an ED physician performed a simple laceration repair prior to APCs, the hospital would have billed only for the supplies or medications administered to the patient (i.e., a tetanus shot). Now, however, the hospital will need to make sure it is reporting the CPT code for suturing (12001-12021) if it expects to be reimbursed. The physician's report in this case would not provide an accurate description of all of the service because the doctor would more than likely code for the visit only. While CPT coding will drive the reimbursement, diagnosis (ICD-9) coding will continue to be important to medical necessity.

E/M Levels May Not Be Equal
 
 
Since the inception of APCs, hospitals can bill an E/M service and get paid for it independently of the ED physician service. Because CMS expects each facility to establish its own E/M guidelines, these guidelines must be readily available during an audit.
  
According to the Federal Register, Apr. 7, 2000 (page 18451), the following policy states:

As long as the services furnished are documented and medically necessary and the facility is following its own system we will assume that it is in compliance with these reporting requirements as they relate to the clinic/ emergency department visit code reported on the bill. Therefore, we would not expect to see a high degree of correlation between the E/M code reported by the physician and that reported by the facility.

The ED facility E/M level and the codes for the surgical and other procedural services must reflect the full package of services provided, not just those services performed by the ED physician. Therefore, in many instances, the ED facility level may exceed the ED physician level.
 
The combined value of resources provided by all ED personnel and the cost of overhead (room, equipment, supplies, etc.) outweighs the services provided by just the ED physician. If a hospital submits a claim based on what the ED physician documents, it will likely lose money because it undervalued the ED facility service.
 
Many coders still apply the principles of physician coding to the facility because CMS has yet to standardize E/M documentation guidelines for hospitals.
 
"Coders tend to look solely at the E/M level the doctor has documented when reporting the facility E/M services," Earp says. Working from two reports provides twice the amount of information, which helps to ensure accurate billing.

In some cases, however, the ED physician may be able to document a high-level visit, but the facility cannot.

 

Scenario 2:
Police bring a psychiatric patient to the ED after finding her roaming the streets and screaming at passers-by. She appears to be responding to internal stimuli, but has given no indication of plans to hurt herself. Her thoughts are scrambled, and her responses are frequently inappropriate.
 
The ED physician performs a complete workup and obtains the past, family and social history (PFSH) on the phone from her family. It is determined the patient is schizophrenic and has not been taking her medication. The ED physician administers an IV of Haldol and admits the patient.
 
 

Coding Solution:
In this case, little treatment is required by the staff (likely a level two, 99282, emergency department visit for the evaluation and management of a patient, which requires an expanded problem focused history and examination and medical decision-making of low complexity). However, because the ED physician must perform an extensive exam and history, the E/M level will score much higher (likely a level four, 99284).