Visit the Facility Side of ED Coding
Improve your coding acumen by understanding the differences between ED facility and ED physician coding.
When coding for the emergency department (ED), there are differences in how facility and professional services are determined. You must be aware of these differences, and understand that the codes assigned by the ED facility coder may not match those assigned by the ED physician coder.
Why the Difference?
The CPT® codebook was originally intended for physician use. As such, the Centers for Medicare & Medicaid Services (CMS) has directed that when using the CPT® codebook for facility coding, the words “physician,” “provider,” and “supervised by the physician” should be omitted when interpreting code descriptors.
Another difference is the concept of “global surgical periods” does not apply to the ED. Only when a procedure is performed on the same day as another procedure is it necessary and appropriate to assign modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period, modifier 78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period, or modifier 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period.
Finally, many facility services are assigned by a chargemaster, rather than by an actual coder. The facility coder must know which codes they are required to assign to avoid omission or duplication of reimbursable services.
Acuity Levels in the ED
ED facility evaluation and management (E/M) levels are assigned using CPT® ED services codes 99281-99285 and, in some instances, critical care codes 99291-99292. There is no direct correlation between the facility E/M level and the professional/physician level of service.
According to the 2003 Outpatient Prospective Payment System proposed rule (August 9, 2002, Federal Register, Vol. 67, No. 154, 52133), “Each facility should develop a system for mapping the provided services or combination of services furnished to the different levels of effort represented by the codes … as long as the services furnished are documented and medically necessary and the facility is following its own system, which reasonably relates to the intensity of hospital resources to the different levels of HCPCS (CPT) codes, we will assume that it is in compliance.”
Based on these guidelines, ED facility E/M codes represent the facility resources related to the encounter, rather than the provider’s professional expertise. The acuity level also typically accounts for those services not otherwise captured. For instance, if a wound (laceration) repair is performed during the ED visit, the services that constitute part of the global package for the laceration repair—such as the suture tray, dressing, and local anesthesia—are included in the laceration/wound repair code, and no additional credit is considered in the acuity level.
Facilities may use any methodology they wish to determine acuity levels. Most facilities choose a point system. Each service that uses facility resources is assigned a set number of points, based on the resources expended. The total points assigned determine the acuity level without regard to the physician’s E/M level. Other facilities look to the presenting problem as the basis in determining the acuity level.
Whatever method is adopted, the facility must be consistent in its acuity level assignment, conform to the guidelines as outlined in the Federal Register, and meet the “intent” of the CPT® descriptors.
Critical Care in the ED
Critical care codes also differ for facilities. CMS allows reimbursement only for 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes, regardless of the time spent attending to the patient’s medical needs. And, whereas physician billing excludes services such as interpretation of cardiac outpatient measurements, chest X-ray interpretations, pulse oximetry, blood gas analysis, intubation, and temporary transcutaneous pacing, etc. (see CPT® for a complete listing), these services are separately reportable when provided in the facility.
Consider this scenario:
A patient arrives at the ED complaining of chest pain and during the encounter becomes critically ill, requiring the one-on-one attention of the physician for a total of one hour and 45 minutes. The physician interprets two sets of chest X-rays, and it becomes necessary to intubate the patient and place a temporary transcutaneous pacer.
- 99291-25 *99292 is not billable/reimbursable by facility
- 31500 Intubation, endotracheal, emergency procedure
- 92953 Temporary transcutaneous pacing *not billable by physician; included in critical care code
- +99292 x 1 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)
Several modifiers may be used by both facilities and physicians but are applied differently.
For example, the ED facility assigns modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service anytime an encounter is performed at the same time as a procedure designated as payment status indicator (PSI) “S” or “T.”
PSIs are assigned to each CPT® code for facility reimbursement, and designate the payment methodology for each service. Payment status S indicates “significant services, not subject to discounting;” and payment status T procedures are subject to discounting when multiple procedures from this classification are assigned. With the use of PSIs, it isn’t necessary to append modifier 51 for multiple surgical procedures.
ED facilities do not use physician modifiers 52 Reduced services and 53 Discontinued procedure, substituting modifiers 73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia and 74 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia in their place. Facilities may use modifier 52 for a partial reduction of services or the discontinuance of services that do not require anesthesia in the facility setting.
Consider this scenario:
The patient arrives for diagnostic esophagogastroduodenoscopy (upper GI endoscopy). The patient is prepped for surgery, anesthesia is administered, and the scope is placed in the esophagus and the stomach; however, the scope is unable to advance into the duodenum and/or jejenum as defined by CPT® 43235 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).
Facilities use modifier 59 Distinct procedural service much the same way as physician offices do: to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.
For example, three benign lesions are excised from the arm, each 2.0 cm in diameter.
11402 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm *first lesion
11402-59 *second lesion, distinct from the first
11402-59 *third lesion, distinct from the first/second
Now consider this example of incorrect use of modifier 59 for both the facility and the physician:
The patient undergoes repair of non-union of carpal bone fracture, during which it’s necessary to remove some hardware from the previous fracture repair attempt.
25431-RT Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each bone–Right side
20680-59 Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)
National Correct Coding Initiative (NCCI) edits indicate that 20680 is a component of comprehensive procedure code 25431-RT. It is inappropriate in both the physician and facility settings to assign both of the above codes if the removal of implant(s) is performed at the same surgical site, during the same surgical session.
Unique to the outpatient facility side is modifier 27 Multiple outpatient hospital E/M encounters on the same date. In addition, condition “GO” is assigned on the UB-04 claim form when multiple visits from within the same revenue center on the same date are performed. Facilities may be reimbursed when more than one E/M is performed on the same calendar date.
For example, a patient arrives in the ED at 10:07 a.m. for complaints of severe headache. Treatment is provided and the patient is discharged. At 7:00 p.m., the patient returns with worsening complaints of severe headache accompanied by nausea, vomiting, and severe photophobia. The patient is treated again and discharged.
On the physician side, it’s inappropriate to code and bill for two ED visits for the same physician/physician group; on the facility side, however, coding would be:
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… *(or the appropriate ED level) for visit at 10:07 a.m.
99282-27 *(or the appropriate ED level) for visit at 7:00 p.m.
Infusions/Hydration in the ED
Because of direct supervision, the infusion/hydration codes typically are not coded in the physician’s office or reported by the physician in the facility setting. These services are usually provided and reported by the facility.
Per CMS, these services are assigned a coding hierarchy, as follows:
- Chemotherapy infusion (minimum time required or code as intravenous push (IVP))
- Chemotherapy IVP
- Medication infusion (minimum time required or code as IVP)
- Medication IVP
Only one “initial” code from this series of codes may be assigned per encounter. Intravenous infusion and hydration codes require a minimum documented time to assign the corresponding codes.
- For example, a patient presents to the ED and the following injections/infusions are provided by the ED staff:
- IVP Dilaudid at 10:00 a.m.
- IVP morphine at 11:00 a.m.
- IV Infusion of Rocephin® from 8:00-9:00 a.m.
- IV hydration from 7:00-8:00 a.m.
The following is assigned:
96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour *for IV administration of Rocephin® 8:00-9:00 a.m. (minimum time met – highest in hierarchy)
All other services must be reported with subsequent codes:
+96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) x 2 *for the dilaudid at 10:00 a.m. and the morphine at 11:00 a.m.
+96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) *for IV hydration 7:00-8:00 a.m.
The same drug/substance may be assigned only once per encounter. For instance, if multiple IVPs of the same drug/substance are administered, +96376 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure) may be assigned for greater than 30-minute intervals; however, no additional reimbursement is made.
To assign hydration codes, the hydration must be medically necessary and not for the purpose to “KVO” (keep vein open) or “TKO” (to keep open).
Marsha S. Diamond, CPC, CPC-H, CCS, is employed by Medical Audit Resource Services, Inc., (MARSI) of Orlando, Fla., which provides compliance and auditing needs for physicians, facility (inpatient and outpatient), and HCCs. She has been involved in medical coding, compliance, billing, healthcare reimbursement, education, and management for over 30 years. Diamond is the author of multiple coding textbooks and various coding and compliance-related articles. She is an instructor and department chair for health information technology in Central Florida, and has served as president of the Greater Orlando, Fla., local chapter for a number of years.