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Wiki ED review
- Thread starter NJcoder
- Start date
jimbo1231
Expert
Review What?
Laurie,
Exactly what will you be reviewing?I'm guessing it is an ED documentation/coding review. Review implies it is retrospective ie already billed. Is that correct? Is it for professional services, facility services or both?Are you expected to give feedback on documentation/coding with reasons for variences between what you found and what was coded? Are you being asked to review any other ED processes? Are they looking for the review to include billing/payments etc.
As you can see, there are a lot of possible flavors of an ED review.
Jim
Laurie,
Exactly what will you be reviewing?I'm guessing it is an ED documentation/coding review. Review implies it is retrospective ie already billed. Is that correct? Is it for professional services, facility services or both?Are you expected to give feedback on documentation/coding with reasons for variences between what you found and what was coded? Are you being asked to review any other ED processes? Are they looking for the review to include billing/payments etc.
As you can see, there are a lot of possible flavors of an ED review.
Jim
jimbo1231
Expert
Facility Side
I'd be interested in what others have to say. The challenge on the facility side is that there, at least yet, are no specific guidelines on levelling like 95-97 on the physician side. The general guidelines basically state that the Levels must be auditable (which you are doing) and reasonably relate to resources utilized etc. So basically you have to review the Levels based on the Levelling tool the ED is using assuming that the tool is reasonable( and the tool could be the problem in some cases). So if it's a point system, are the resources and services that have points identified and added properly? If it's ACEP, per the ACEP guidlines are all of the necessary resources, procedures etc documented to support the Levels. If you are outsourceing what is their tool?
One quick thing you can do as a starting point is just look at the acuity percentages for the period you are auditing. If a Level seems overutilized either high or low you might focus the audit there a bit. I've done a fair amout of research on facility Levels, and there still is quite a bit of variance on the way levels are coded. Or a more focused audit could result from initial findings.
If you wanted to provided me with the acuites privately, no PHI about the facility of course, I could at least give you a feel about your levels since I've looked at hundreds of ED facility Levels over the last few years.
Big brother is looking at 99285 since there has been a dramatic increase in recent years. And 99285s admitted are not coded. so auditing regularly is necessary.
jim
I'd be interested in what others have to say. The challenge on the facility side is that there, at least yet, are no specific guidelines on levelling like 95-97 on the physician side. The general guidelines basically state that the Levels must be auditable (which you are doing) and reasonably relate to resources utilized etc. So basically you have to review the Levels based on the Levelling tool the ED is using assuming that the tool is reasonable( and the tool could be the problem in some cases). So if it's a point system, are the resources and services that have points identified and added properly? If it's ACEP, per the ACEP guidlines are all of the necessary resources, procedures etc documented to support the Levels. If you are outsourceing what is their tool?
One quick thing you can do as a starting point is just look at the acuity percentages for the period you are auditing. If a Level seems overutilized either high or low you might focus the audit there a bit. I've done a fair amout of research on facility Levels, and there still is quite a bit of variance on the way levels are coded. Or a more focused audit could result from initial findings.
If you wanted to provided me with the acuites privately, no PHI about the facility of course, I could at least give you a feel about your levels since I've looked at hundreds of ED facility Levels over the last few years.
Big brother is looking at 99285 since there has been a dramatic increase in recent years. And 99285s admitted are not coded. so auditing regularly is necessary.
jim
Hi Jim, thanks for your feedback.
They use ACEP guidelines..and I thought those guidelines are for the physician side of billing? This is the facility side.
E/M confuses me. Would love to discuss more with you...any tools or audit sheets you can recommend? Or a crash course?!?
Thank you.
They use ACEP guidelines..and I thought those guidelines are for the physician side of billing? This is the facility side.
E/M confuses me. Would love to discuss more with you...any tools or audit sheets you can recommend? Or a crash course?!?
Thank you.
mitchellde
True Blue
The facility must have their own "tool" for evaluation of the E&M level. It must be used across the board for all patients. If a particular procedure/service has a unique CPT code then it cannot be counted as an element on your tool. Every facility is required to develop their own criteria, it does not have to match anyone elses. So the first step is to obtain a copy of your facilities "tool" and then evaluate it.
jimbo1231
Expert
ACEP Guidelines
Laurie,
The ACEP Guidelines are for the facility side. ACEP and others like Lynx came up with guidelines based on resources utilized, procedures etc since there are no specific guidelines for ED facility coding. The 95/7 Guidelines are all that History/Physical/Medical Decision Making stuff for physician coding developed by CMS and the AMA in the 90s.
ED coding on either the physician or facility side is a bit involved for a crash course. ACEP does an annual Coding Meeting that includes optional classes for new coders. Think it's in Orlando this winter (not a bad spot). Industry types like Jim Blakeman, Caral Edelberg and others as well as me also do ED coding training.
And the CEDC course on the AAPC site is a good intro to ED coding. But it is about the physician side not the facility. I'm not sure if there is really comprehensive training for ED facility coding. AHIMA had proposed guide lines a few years ago and they are out there. But not sure if they have a comprehensive course related to ED facility coding. But there are a number of seminars out there if you google.
If you would like to further discuss with me I'm at jstrafford@hapusa.com
Jim
Laurie,
The ACEP Guidelines are for the facility side. ACEP and others like Lynx came up with guidelines based on resources utilized, procedures etc since there are no specific guidelines for ED facility coding. The 95/7 Guidelines are all that History/Physical/Medical Decision Making stuff for physician coding developed by CMS and the AMA in the 90s.
ED coding on either the physician or facility side is a bit involved for a crash course. ACEP does an annual Coding Meeting that includes optional classes for new coders. Think it's in Orlando this winter (not a bad spot). Industry types like Jim Blakeman, Caral Edelberg and others as well as me also do ED coding training.
And the CEDC course on the AAPC site is a good intro to ED coding. But it is about the physician side not the facility. I'm not sure if there is really comprehensive training for ED facility coding. AHIMA had proposed guide lines a few years ago and they are out there. But not sure if they have a comprehensive course related to ED facility coding. But there are a number of seminars out there if you google.
If you would like to further discuss with me I'm at jstrafford@hapusa.com
Jim
mitchellde
True Blue
There was a coding clinic for HCPCS several years back that did an excellent job on facility E&M coding, I do not remember which issue though.
thank you Michelle and Jim.
I will research for that coding clinic and look for the ACEP guidelines for facility coding.
Jim, do you have any audio conferences, etc. that I may purchase to brush up on ED coding? I am fine with icd/cpt coding, it's the E/M that confused the heck out of me
I will research for that coding clinic and look for the ACEP guidelines for facility coding.
Jim, do you have any audio conferences, etc. that I may purchase to brush up on ED coding? I am fine with icd/cpt coding, it's the E/M that confused the heck out of me
jimbo1231
Expert
No audio
Laurie,
Sorry, my only audio is me actually speaking with you. Again the CEDC curriculum is good and includes audio. And there are various articles in Coding Edge about ED E&M Coding if you look through the archives. I have presentations, but taking on ED coding in general is a tall order. And since there is some subjectivity involved in E&M Coding, my view might differ from other very expeienced AAPC members who I respect. So I don't go there. But again try the above resources.
Jim
Laurie,
Sorry, my only audio is me actually speaking with you. Again the CEDC curriculum is good and includes audio. And there are various articles in Coding Edge about ED E&M Coding if you look through the archives. I have presentations, but taking on ED coding in general is a tall order. And since there is some subjectivity involved in E&M Coding, my view might differ from other very expeienced AAPC members who I respect. So I don't go there. But again try the above resources.
Jim