Next Step in ED Leveling: Evaluation Methodologies

Part 2: Once you’ve evaluated performance, refer to the four most frequently used leveling methods.

by Jim Strafford, CEDC, MCS-P
In “Evaluate Your Performance When ED Leveling” (January 2011 Coding Edge, pages 46-48), we discussed methods to determine whether your emergency department (ED) levels are appropriate based on Outpatient Prospective Payment System (OPPS) guidelines. We also noted that the 1995 and 1997 Documentation Guidelines for Evaluation and Management (E/M) Services do not apply to facility-side ED coding. Instead, the Centers for Medicare & Medicaid Services (CMS) directs hospitals to develop guidelines according to general recommendations, including:

  • Follow the intent of the CPT® code descriptor: CMS is looking for higher E/M levels based on increased hospital services.
  • Base levels on hospital facility resources, not physician services: As such, the use of physician E/M guidelines is inappropriate.
  • Guidelines should not facilitate upcoding: Hospital leveling guidelines should not encourage coding not supported by documentation.

The lack of specific ED leveling guidelines has resulted in a proliferation of ED facility leveling methodologies. The four methods we’ve reviewed and found to be used most frequently are:

  • Point Systems
  • Matrixes
  • American College of Emergency Physicians® (ACEP) Method
  • Commercial Hybrid Systems

Here is a description and analysis of each methodology.

Point Systems

Using a point system methodology, points are assigned for services, procedures, and hospital resources used by hospital employees, particularly nurses in the ED. Point values typically increase as the intensity of the services, procedures, time, and resources used increase. Usually, points are assigned for changes in patient status, such as “admit” or “transfer,” because of the hospital resources used in completing these changes.
The sample shown in Table 1 is relatively simple, with only four possible point values for hospital or nurse services: five, 10, 15, or 20. An example of a five point service is application of a Steri-Strip or a sling by hospital personnel, such as a nurse or technician, but not by a physician (because this is part of ED professional coding). A 10-point service might be blood pressure (BP) monitoring, providing emotional support, or accompanying a patient to lab or radiology. A 15-point service might be an intravenous (IV)-insertion, or pelvic exam. A 20-point service is reserved for the most resource- and time-driven services, such as admit to intensive care unit (ICU), assist with newborn care, or restraining/managing a combative patient.
The coding methodology is simple. The coder identifies these services on the ED chart and assigns the appropriate number of points for each service, procedure, etc. The coder then adds the total points, and follows level guidelines based on the total points. In our example, if points exceed 60, 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 is assigned; if they exceed 100, 99285 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity is assigned.
Table 1: The Point System 

5 Points 10 Points 15 Points 20 Points
Initial Assessment BP Monitoring Pelvic Exam Admit ICU/CCU
Wound Cleanse Simple Apply Clavicle Strap Transport to ICU Restraints Apply/Monitor
Topical Meds Foley Cath Simple Enema/Disimpaction Cardiac/Thrombolytic Agents
Ace Wrap Emotional Support Multiple VS Checks Rape Exam
Urine Dip Cardiac Monitoring IV Insertion Multiple IV Infusions
Steri-Strip Application Accompany to Lab or Rad Newborn Care


5-20 points








50 or more


60 or more


For a point system to work properly, it is critical that all possible ED hospital services, procedures, and resources used are identified and itemized. Please note our example is limited. You will need to devise a method for assigning fair relative weight to each service to achieve an accurate point system. If your point system results in either very low or very high acuity coding (See “Evaluate Your Performance When ED Leveling,” referenced above), review the point system methodology.
Point systems are relatively easy to use and don’t require a strong coding background, but there can be a number of issues. The first is simple math. Correctly adding the points is crucial to getting the levels correct. Incorrectly adding or identifying the elements that have points can result in undercoding. Point systems also typically don’t weigh in coding issues such as severity of presenting problem. The result is a rote method that has very little to do with coding, and doesn’t always account for chief complaint and the resulting work and resources required to treat the patient.
Table 2: The Matrix Approach 

99281 99282 99283 99284 99285
Prescription Refill Abscess-Simple Headache-Simple Headache-Complex Chest Pain-Cardiac
Wound Check-Simple Simple Rash Cellulitis Head Injury w/LOC Cardiac Monitoring
Steri-Strip Wound Insect Bite/Simple Neb Treatment Blood-Transfusion Multiple IV
Triage Only Cast Removal Sprain Can’t Bear Weight Pelvic Exam Admit ICU/CCU
Epistaxis No Packing Epistaxis w/Packing Vaginal Bleeding GI Bleed
Dental Pain Burn Treatment Neb Treatment-Multiple Severe Resp. Distress
Abdominal Pain Simple Abdominal Pain-Complex Epitaxis Complex/IV
Respiratory Distress
Lab Orders
Chest Pain Simple

Matrix Approach

A second approach to coding facility levels involves building a matrix that itemizes the hospital resources used and the procedures rendered in the ED by hospital personnel, and ties them into CPT® levels of service. This matrix mixes patient symptoms or diagnoses with ED hospitals services that typically are rendered for each level of service.
In our example, shown in Table 2, the coder would:

  • Identify a patient condition (such as chest pain), hospital resources, and nurse of other ED personnel services or procedures that go with chest pain. For example, hospital resources used for chest pain are electrocardiogram (EKG), labs ordered, etc. These are listed under the matrix example of level 4, and result in coding of 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.

Treatments could appear under different matrix levels depending on the complexity of the patient problem and treatment, so a simple nosebleed with no packing might be associated with 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. But, a complex nosebleed requiring extensive packing and other services such as labs and/or IV—and the associated nurse hospital resources and time required—might result in a 99285.


The matrix method, like the point system, requires that patient problems and complaints, as well as ED hospital treatment, are associated with the appropriate level of service. Also, the matrix must be complete in providing example patient conditions, services, and procedures that are associated with each level.
The simple matrix is closer to coding than the point system in that it recognizes what would be presenting problems, symptoms, and diagnoses, and the treatments that go with them. This allows the coder to weigh more factors than a rote point system, but greater coder decision-making is required to prevent under- and over-coding—particularly with patient complaints that could go with multiple levels, such as chest or abdominal pain. As with the point system, elements of the matrix must be associated with the appropriate level of service and must be complete in identifying ED resources used.

ACEP Facility Level Guidelines

A methodology that combines the best of the matrix approaches and point systems is the ACEP’s ED Facility Level Coding Guidelines ( The guidelines associate interventions and possible interventions with each level of service. Unlike with point systems, additional interventions that are associated with lower levels are not added to arrive at a level. The ACEP method builds logically from level to level with examples of additional services or more acute symptoms to support higher levels. ACEP guidelines also provide typical symptoms that, along with the intervention, support the level of service.
ACEP guidelines include three columns. The first column indicates the level. The second column indicates possible interventions. The third column contains symptoms/ examples that support the levels.
One example of level 3 (99283) under possible interventions is nebulizer treatment; the associated symptom from column 3 is mild dyspnea not requiring oxygen. Multiple nebulizer treatments that typically are associated with more severe dyspnea correlate with level 4 (99284).


The ACEP guidelines provide instructions and examples. These are relatively user friendly and less arbitrary than point systems. The guidelines and possible interventions, and symptoms and examples that support the levels, are based on and developed by ED physician’s clinical experience. The result is a complete menu of services and procedures rendered in the ED. When used correctly, the ACEP guidelines can be a very good choice.
ACEP also provides nature of presenting problems in their instructions. Although these are not an essential element of leveling instructions, they do focus the coder on real-world situations encountered in the ED, with more complex presenting problems usually associated with higher levels. In incorporating presenting problems, the ACEP approach feels more like actual coding than other approaches.

Commercial Level of Service Systems

Several marketed systems produce ED levels based on elements factored by proprietary software (for example, by factoring many possible presenting problems with intervention examples to calculate levels). Two such ED facility coding systems are the Picis LYNX E/Point® system and Horizon Intelligent Coding™ by McKesson.


These systems can be effective. If you’re considering such a system, compare several products in terms of price, user friendliness, and features. Consider also speaking with current and former clients.

People Make the Difference

Regardless of methodology, the personnel performing ED leveling are critical. Our experience shows that personnel doing this work should be experienced ED coders; however, in many hospitals, nurses, medical records coders, or even clerks do the leveling. This can only work with complete guidelines, proper training, and ongoing review. If a hospital cannot make the time and investment necessary to properly perform ED facility coding, outsourcing (very common on the physician side of the ED) is an option. Only consider reputable companies, and be sure to check references. There also are organizations that do outsourced ED facility coding, such as Medical Management Professionals, Inc. (MMP), Medical Recovery Specialists, Inc. (MRSI), and Medical Management Resources, Inc.

Certified Emergency Department Coder CEDC

Jim Strafford, CEDC, MCS-P, principal of Strafford Consulting Inc., has 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 ED revenue cycle and coding issues. He can be reached at and


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No Responses to “Next Step in ED Leveling: Evaluation Methodologies”

  1. Tammy Vannatter says:

    I was wondering if you could give me your thoughts on the question: When can we start calculating time when coding CC for the facility? Once the intervention has started OR if an intervention is provided, can we start counting the 30 minutes (time) at the time of the vitals (first time recorded)?
    This would be if we do not have a provider note with time documented. We follow ACEP facility guidelines, which state that we can code CC if we have interventions and we have 30 minutes or more documented by provider or staff member (nursing notes).
    The bottom line to the question is: once an intervention is done, do we start time then or can we start time at the time of the first vitals recorded by nursing staff?
    Thank you for your assistance,