Beat Three Challenges for Emergency Department Coders
Overcome specialized obstacles that ED coders face.
By Karen Stanley, RN, MBA
Coding and billing for the emergency department (ED) presents unique challenges. We’ll review three such challenges, and provide advice to overcome them.
Challenge No. 1: Facility and Physician Coding Guidelines Differ
The definitions of facility coding guidelines and professional coding guidelines are quite different:
Facility coding guidelines: Based on the volume and intensity of resources used by the facility to provide patient care.
In recent years, to better determine and describe the true severity of illness or intensity of service seen in the ED, an increasing number of hospitals have stationed a clinical documentation specialist or utilization review nurse in the ED. This allows the facility to capture and code patients’ severity of illness and intensity of services and/or resources in real time.
Professional coding guidelines: Based on the complexity and intensity of provider-performed work.
The facility and physician level of care may not be the same intensity for the same encounter, so facility resource con-sumption is captured apart from physician resource consumption. The differences in coding include patients who may see a physician briefly, or not at all, as demonstrated by this frequently-asked question on the Centers for Medicare & Medicaid Services (CMS) website:
“Question: Can hospitals bill Medicare for the lowest level ER [emergency room] visit for patients who check into the ER and are “triaged” through a limited evaluation by a nurse but leave the ER before seeing a physician?
Answer: No. The limited service provided to such patients is not within a Medicare benefit category because it is not provided incident to a physician’s service. Hospital outpatient therapeutic services and supplies (including visits) must be furnished incident to a physician’s service and under the order of a physician or other practitioner practicing within the extent of the act, the Code of Federal Regulations, and state law. Therapeutic services provided by a nurse in response to a standing order do not satisfy this requirement.”
To date, there are no national resources for utilization/intensity of services standards for ED visits. Hospitals have im-plemented their own guidelines, using decision-making tools such as “InterQual criteria” and other coding principles. Per the Outpatient Prospective Payment System (OPPS), the following criteria must be met for facility billing:
- The coding guidelines should follow the intent of the associated CPT® code descriptor, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
- The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources.
- The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits.
- The coding guidelines should meet the HIPAA requirements.
- The coding guidelines should only require documentation that is clinically necessary for patient care.
- The coding guidelines should not facilitate up-coding or gaming.
- The coding guidelines should be written.
- The coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply.
- The coding guidelines should not change with great frequency.
- The coding guidelines should be readily available for fiscal intermediary (or, if applicable, MAC) review.
- The coding guidelines should result in the coding decisions that could be verified by other hospital staff, as well as outside sources.
The American College of Emergency Physicians (ACEP) offers instructions for use of the ACEP facility coding model, “ED Facility Level Coding Guidelines,” on its website. The model provides examples with possible interventions.
Challenge No. 2: Not All EDs Are Created Equal
According to CMS, there are two levels of ED visit codes: Type A and Type B.
Type A: An ED is available to provide services 24 hours a day, seven days a week, and meets one or both of the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements for dedicated EDs as specified at 42 CFR 489-240 (B):
– It is licensed by the state in which it is located under the applicable state law as an emergency department.
– It is held out to the public as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.
Type A ED visits include five levels of care, in addition to a critical level:
Level 1 – 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.
Level 2 – 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.
Level 3 – 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.
Level 4 – 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.
Level 5 – 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.
99291 Critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes
+99292 each additional 30 minutes (List separately in addition to code for primary service)
Type B visits apply to an ED with EMTALA obligations that do not meet the CPT® definition of an ED. The services are described by HCPCS Level II codes G0380-G0385, plus critical care (G0390 Trauma response team associated with hospital critical care service) and observation (G0378 Hospital observation service, per hour and G0379 Direct admission of patient for hospital observation).
For hospital ED visits, the Type B ED must meet at least one of the following requirements:
- It is licensed by the state, under applicable state law as an ED.
- It is held out to the public as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.
- During the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on a an urgent basis without requiring a previously scheduled appointment.
Bottom line: Before assigning codes in the ED, you have to know what kind of ED you’re billing. From there, you must assign a level using facility resources (not physician effort) as the determining criteria.
Challenge No. 3: Appending Modifier 25 Correctly
In 2005, the Office of Inspector General (OIG) reviewed the use of modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service in 415 randomly selected claims. Of those, 35 percent of claims did not meet program requirements, resulting in $538 million in improper payments (see OIG Executive Summary, November 2005, ).
The ED has higher levels of acuity for the facility, as well as for the physician, so the use of modifier 25 is justified in some instances. Due to what the OIG determined as abuse, the following recommendations were made to CMS to reduce the number of modifier 25 claims:
- Reinforce the requirements that evaluation and management (E/M) services billed using modifier 25 are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure.
- Encourage carriers to emphasize that appropriate documentation of both E/M services and procedures must be maintained to support claims for payments using modifier 25, even though the documentation is not required to be submitted with the claims.
- Emphasize that modifier 25 should only be used on claims for E/M services, and only when these services are provided on the same day as another procedure.
To cite a few examples, the ED physician would likely perform and document a separate E/M for:
- New onset of post-menopausal bleeding when an endometrial biopsy is performed after the evaluation.
Patient presents with anemia and bleeding and a surgeon decides to perform an endoscopy.
- Initial evaluation for a non-healing wound and a procedure on the wound itself.
Keywords for the coder to look for when using modifier 25 are “the patient’s condition required” or mention of “significant” services “above and beyond” other services rendered. For instance, consider a case where a patient is seen in the ED with a complaint of a rapid heartbeat, and a 12-lead electrocardiogram (ECG) is performed. In this case, you may report 99281-99285 with modifier 25, and 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report.
You would be less likely to report both an E/M and a procedure in these clinical situations:
- For a planned, repeat procedure such as wound care
- For a patient who presents for the procedure (e.g., “Patient presents today for a LEEP after an abnormal Pap smear”)
- For minor procedures, such as lesion destruction
- For planned, routine foot care provided to nursing home patients
Do not use modifier 25 when the only service provided is the procedure. For example, a new, otherwise healthy, 18-year-old patient presents to urgent care for a second-degree burn on the hand. The physician takes a brief history, examines the hand, and applies a dressing to the wound. This would most likely be reported 16020 Dressings and/or debridement of partial thickness burns, initial or subsequent, small (less than 5% total body surface area). It would probably not be necessary to perform a significant E/M service in this case.
Lastly, you should not apply modifier 25 to describe an E/M service that results in the decision to perform surgery (this circumstance is indicated by modifier 57 Decision for surgery).
Karen Stanley, RN, MBA, is clinical documentation specialist at Providence Hospital in Washington, D.C.
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