APC Implementation Will Warrant Coding Compliance
Published on Sat Jul 01, 2000
Nugget: Hospitals will be required to identify all services provided to the patient during an emergency department visit when the ambulatory payment classification rules take effect on Aug 1, 2000. With this inevitable change, optimum reimbursement will be gained only with a clear understanding of the APC coding process.
By now many of you are breathing a big sigh of relief that the implementation of the ambulatory payment classifications (APCs) of the outpatient prospective payment system (OPPS), has been postponed by HCFA until Aug 1.
Since the release of the APC final rule, many coders have received numerous inquiries from hospital administrators relating to use of the emergency physician CPT codes for assigning the hospital emergency department (ED) assessment levels and procedures. Although this might seem like a natural correlation, the general information available for comparison of physician and facility coding criteria and analysis of the final APC rule indicate that it is not in the best financial interest of most hospitals to code in this manner.
Additionally, use of the distinct emergency physician codes may result in compliance issues due to incomplete code assignment for the hospital portion of the service due to the reasons outlined below.
Under APCs, the hospital will be required to identify all services provided to the patient during the emergency department stay. In numerous cases, the emergency physician is but one of two or more physicians who may examine and treat the patient.
The ED facility level, as well as the codes for the surgical and other procedural services, must reflect the full package of services provided, not just those services performed by the emergency physician. Therefore, in many instances, the emergency department facility level may exceed the level billed by the emergency physician.
Due to coding constraints placed on physicians when their documentation does not meet or exceed established documentation guidelines, emergency department coders may be forced to down-code the emergency department levels by one or more codes. These constraints do not affect the hospitals coding of the emergency department facility level. For example, the medical decision-making level in both physician and nursing documentation indicates a moderate level evaluation and management (E/M code 99284), but the physician provides a more limited history and physical examination that would result in a lower physician code (99283).
Most coders and ED practice administrators provide educational programs to their emergency physicians, but due to the hectic pace in the emergency department and, on occasion, the limited time a physician has to document a complete medical record prior to the patients discharge from the ED, certain components of the documentation may occasionally be omitted. Use of these down-coded levels will result in a negative financial impact on the hospital.
Time-Based Coding
The emergency [...]
