Evaluate Your Performance When ED Leveling

By Jim Strafford, CEDC, MCS-P

How well does your emergency department (ED) assign evaluation and management (E/M) levels based on the resources used? How does your facility compare to other, similar facilities? If you don’t know the answers, it’s time to take a closer look at your facility E/M leveling.

Evaluation and Management – CEMC

Review Guidelines

The Centers for Medicare & Medicaid Services (CMS) requires hospitals to report ED facility resources using CPT® E/M services codes. But, whereas the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services direct E/M leveling for physician services, there are no standard leveling guidelines when reporting facility resources (see Medicare Claims Processing Manual, chapter 4, section 160: www.cms.gov/manuals/downloads/clm104c04.pdf). Instead, each hospital must develop its own, internal guidelines, based on 11 general principles that CMS outlined in the 2008 Outpatient Prospective Payment System (OPPS) Final Rule (see Federal Register, Nov. 27, 2007, page 66805: http://edocket.access.gpo.gov/2007/pdf/07-5507.pdf).

Among other requirements, CMS expects each hospital’s internal guidelines to:

  • Follow the intent of the CPT® code descriptor (the guidelines should relate reasonably to the hospital resources used)
  • Be based on hospital facility resources, not physician resources
  • Be clear to facilitate accurate payments
  • Not facilitate upcoding
  • Be written or recorded, be well documented, and provide the basis for selection of a specific code

As long as these general guidelines (and seven others) are met, CMS allows the hospital (or, more precisely, its coders) to decide how ED services should be documented to support a given service level. The result has been a hodgepodge of methodologies, including point systems, matrixes, and hybrids of both (look to future articles for a discussion of these differing methodologies).

How Do You Compare?

CMS states in the 2010 OPPS Final Rule, “CMS continues their belief that based on the use of their own internal guidelines, hospitals are generally billing in an appropriate and consistent manner that distinguishes among different levels of visits based on their required hospital resources.” (See Federal Register, Nov. 20, 2009, page 60552: http://edocket.access.gpo.gov/2009/pdf/E9-26499.pdf.) At Strafford Consulting, review of Medicare data indicates (in a very general way) CMS’s statement may be true; however, many hospitals are well below or well above national averages.

Table A gives Medicare acuity levels for four EDs in a densely-populated Northeast state. The EDs are similar in payer mix, volume, and patient mix. So why is there such a variance in leveling among these hospitals?

Table A:

2009 Medicare Leveling Data for Four EDs in East Coast Suburban Areas Close to Large Urban Areas

Level 99281 99282 99283 99284 99285
ED 1 2.54% 56.21% 28.27% 9.05% 3.92%
ED 2 1.39% 27.97% 37.17% 22.70% 10.77%
ED 3 1.81% 24.73% 69.01% 3.80% 0.66%
ED 4 12.08% 16.65% 15.04% 16.08% 40.16%
Medicare Average 5% 16% 33% 31% 16%


Table A illustrates:

•  EDs 1 and 2, which have visits in the 30-40K per annum range, are moderate size EDs.

•  EDs 3 and 4, which have visits in the 70-80K per annum, are moderately large EDs.

•  EDs 1-3 are well above national averages for 99282 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity.

¦  ED 1 shows over three times the national average for 99282. This could indicate a leveling issue that is affecting revenue.

¦  Only ED 4 is in line with national averages for 99282.

•  All of the EDs are well below the national averages for 99284 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and medical decision making of moderate complexity. This could represent a very significant revenue loss.

•  ED 4 is well above the national average for 99285 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and medical decision making of high complexity. If the coding is not supported by documentation and medical necessity, this ED could be vulnerable to negative audit findings and major paybacks.

Different practice patterns and resource use may affect acuity levels. For example, a given hospital might have a very robust walk-in clinic in the ED. But this report tracks Medicare patients who typically are sicker than the general population when visiting the ED. Because CMS and CPT® do not provide guidelines for leveling, the major reason for the leveling differences likely is the leveling method each hospital uses, and the quality of documentation at these EDs.

This example shows why you should examine E/M leveling in your facility.

Be Sure Used Guidelines Are Complete and Capture All Supported Services

As a first step, review your reports and work-up percentages based on ED acuity levels. If your ED is coding 99281 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making and 99282 over 50 percent of the time, you could be undercoding ED levels. If the majority (60-70 percent) of your levels are 99283 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity, you might be suffering from “Level-3-itis.” This is still a common issue with physicians who do their own coding (such as hospitalists). On the other hand, if your ED is coding 99285 more than 40-45 percent of the time, there could be a compliance issue.

If your ED leveling percentages are way out of line, it is likely that the guidelines you use for leveling are not complete in capturing all elements that can support the services. Or, the personnel who do the leveling are not identifying all of the elements that would support an ED level. In the later case, the problem may relate to who does the leveling at your hospital. ED nurses are responsible for leveling at some hospitals; and they are most familiar with resources utilized in the ED to support levels. Like physicians, though, nurses often do not have the time or inclination to focus on leveling.

Recognize also that atypical leveling patterns may attract CMS’ attention. The 2010 OPPS Final Rule (referenced above) states, “In the absence of national guidelines, we [CMS] will continue to regularly reevaluate patterns of hospital outpatient visit reporting at varying levels of disaggregation below the national level to ensure that hospitals continue to bill appropriately and differentially for these services.”

Who Is Responsible for Leveling?

Many hospitals use medical records, or a coder/leveler who is based in the ED (a very good choice for ongoing interaction with ED personnel), to do some combination of the leveling, procedure coding, and ICD-9 coding. This is a great approach if the coder/leveler is trained properly, with complete guidelines and ongoing review and feedback. Some hospitals outsource the ED facility coding to firms that specialize in ED coding. This also can be a good choice.

Hospitals often seek hospital-side certification for ED leveling positions. Presently, there is no specific certification for facility-side ED coding. AAPC, however, offers a Certified Emergency Department Coder (CDEC™) certification for reporting physician services. CEDCs must pass a demanding exam that consists entirely of ED chart reviews. CEDC certification assures the hospital that the coder has familiarity with ED procedure and ICD-9 coding, and should learn a given hospital’s leveling methodology quickly.

Just remember: Expertise in ED physician coding does not equate automatically to expertise in facility leveling.

Take Steps to Track Your ED Leveling

Based on an analysis conducted by Strafford Consulting, many EDs fall close to national E/M leveling averages. But, in over 200 EDs, codes 99281 and 99282 represent the majority of services for sicker and older Medicare patients. Conversely, there are close to 100 EDs with 99284 levels well below national averages. If your ED is falling well below or above national averages, Strafford Consulting recommends:

•  Thoroughly reviewing your leveling tool and procedures. Are all elements that can be counted toward levels included in the tool? Are services given proper weight toward determining ED Levels?

•  Using available research tools from American College of Emergency Physicians (ACEP) to various point systems. Identify the tool that works best for your ED.

•  Auditing a significant sample of your ED charts.

¦  Review documentation and levels that were coded.

¦  Analyze data to determine whether the issue is chart documentation, your leveling tool, or coder error.

•  Determining if personnel doing leveling are best suited for the job.

•  Educating your staff on audit findings.

•  Scheduling reviews at least twice a year.

•  Seeking advice from an outside consultant, when in doubt.


Jim Strafford, CEDC, MCS-P, principal of Strafford Consulting Inc., has over 30 years experience as a consultant, manager, and educator in all phases of medical coding, billing, compliance, and reimbursement. He is a published, nationally recognized expert on emergency department revenue cycle and coding issues. He can be reached at straffcon@aol.com and www.StraffordConsulting.com.



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