Wiki Coding Correct E/M Level with procedures

[bseidel@correctcareinc.com]

When additional procedures are done in the ER (like suturing, I&D, etc.) do I code a lower E/M level to or can I code the E/M level according to the documentation provided to be in full complaince with all CMS regulations?
Thank you.

 

[jimbo1231]

No, you can't

When I see a question like this I wonder if an OIG or RAC informant is on the site. But I'll assume it's a genuiine question. The simple answer is you always code based on d
ocumentation. You never code for reimbursement. Undercoding is as fraudulent as overcoding.
OK I'll get off my high horse for a minute. The fact is the ED levels that go with procedures usually are lower level based on documentation, presenting problem, MDM etc.
But a person can have a CVA, fall and crack their head. And you might have a laceration repair with a 5 or CC.

Jim

 

[kevbshields]

In order to answer your question more specifically, is this facility or physician coding?

While you must code based on documentation, your facility may have (or should have) a facility-fee charge leveling policy. In other words, the ER coding for facility must be based on a reproducible method. At some places the facility coding accounts for procedures performed and resource utilization. At others, procedures are not as much a factor as intensity of care.

Check with your HIMS leadership and if you're still without guidance, ask if you can research and help write such a policy.

 

[jimbo1231]

Facility Leveling

Kevin,

I agree. But E&M usually indicates professional component coding. But I've seen it used for both sides.
ED facility leveling is a whole other subject probably deserving it's own forum on here. Since as you stated, CMS leaves hospitals on there own in terms of Leveling methodology, my experience is that hospitals are all over the place with Leveling. I've seen hospitals with similar acuity mixes vary wildely in terms of levels. And I agree that some of it could be based on what is bundled into the levels. But it is my understanding that hospitals have been insstructed to follow the intent of CPT (2010 OPPS) which means coding and billing procedures separately. But I've even seen a couple of hospitals still using only three Levels based on old APCs. And there are guidelines from CMS, but none instruct the hospital coder how to determine a Level. So I've seen all kinds of approaches out there from point systems, to ACEP, to acuity matrixes, and hybrids of all of the above. Kind of reminds me of E&M coding before guidelines came in in the 90s.

Jim