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.

Evaluation and Management – CEMC

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:

  1. 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.
  2. The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources.
  3. The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits.
  4. The coding guidelines should meet the HIPAA requirements.
  5. The coding guidelines should only require documentation that is clinically necessary for patient care.
  6. The coding guidelines should not facilitate up-coding or gaming.
  7. The coding guidelines should be written.
  8. The coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply.
  9. The coding guidelines should not change with great frequency.
  10. The coding guidelines should be readily available for fiscal intermediary (or, if applicable, MAC) review.
  11. 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.

Critical Care

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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5 Responses to “Beat Three Challenges for Emergency Department Coders”

  1. Lynn Kelly says:

    I wanted to reach the author of this article. Currently, when a patient leaves the Emergency Department without being seen and was not seen by the physician,we are billing the ancillary services to insurance. Ancillary orders are entered upon triage so that the Physician has the opportunity to evaluate results before seeing the patient. However, if the patient opts to leave before the Physician sees them, are you saying we can not under any circumstances bill insurance for the ancillary services? Please advise or call, 209-339-7550. Thank you.

  2. Munish Kumar says:

    I am not agreed with the last point of this author which states that a new, otherwise healthy, 18-year-old patient presents to emergency 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, It would probably not be necessary to perform a significant E/M service in this case. In ED services only we can bill the procedures both which have 10 days or 90 days global period respectively with modifier 25 or 57 whichever best fitted to the case.

  3. Jacob says:

    RE: Question by Lynn Kelly

    “Since diagnostic services do not need to meet the requirements for incident to services, they may be coded even if the patient were to leave without being seen by the physician.”

    Citation: https://www.acep.org/content.aspx?id=30428

  4. Brian Wilson says:

    Go to the emergency room because I think my daughter has strep throat after we both got off of work nine nine-thirty in the evening on a Friday night needed to find out if she had strep so she could get a doctor prescribed antibiotic so she wouldn’t become more ill dr. Comes in she chats for about 10 minutes she took her blood pressure , temperature then visually examine her throat 5 seconds later “that’s not strep” very confidently saying nope ,not to worry …looks like a calcium deposit build-up ,bad breath it worst diagnosis. ..hooray great news !!!she’s not contagious going to get a fever or need medicine …simple straightforward visit if there ever was one .well they made sure they had my Blue Cross Blue Shield information before they let me go .couple weeks later I got a bill from the physician (level 5) emergency room exam (level 5 ) just below critical condition in amount of over $1,100 then I get billed for EKG ECG tests and interpretations that were never performed didn’t even need to be performed now I’m wondering if I got somebody else’s bill well Blue Cross Blue Shield pay a couple hundred bucks after their adjustment leaving me with $200 to balance .Hospital sent me none itemized bill… just their address my address and over $700 that I owe them for what hey yeah they couldn’t provide me with an itemized receipt .I go to the medical records office and demand for every piece of paper with my daughter’s medical information that’s ever existed well out of everything I got from them which is a whole lot, there’s no relationship relating to the bill I got other than the date of service even the time of evening goes back and forth that that we came in at a quarter to 10 then we were seen 15 minutes before that that maybe is clerical error butt who’s going to take the blame for this fraudulent activity among the ER the hospital itself the medical coders physician and the the physician’s billing department. I’ve got to go after every one of them find out why after I provided Blue Cross Blue Shield insurance for my daughter that was diagnosed with bad breath still have to come up with a thousand bucks….. how’d you like to come home from the grocery store with a piece of paper identifying only where you came from and how much money you left there… not knowing how much your milk and eggs and bread cost or even if you picked those items up , perhaps the bagger didn’t get them in your cart.. who knows who cares

  5. Brian Wilson says:

    Well since the hospital couldn’t provide me with an itemized bill and the physician can’t back up what she bill me for and charge me what it would cost to just have her tonsils removed I need to take her back down there and show that she still has her tonsils and demand I want a refund! I don’t know now that I think about it if they’re going to bill me for stress tests you know EKG ECG and all that jive I think of I’ll have to bring a lawsuit against them for not lawfully abiding by informed consent policy… I bet then they will be quick to admit there was no testing done EKG ECG that was just a honest clerical mistake before having to explain why they would unlawfully fail to discuss any medical procedures or treatment and game my consent

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