Clarify Services by Revising ED Assessment Criteria
Published on Thu Jun 01, 2000
By Caral L. Edelberg, CPC, CCS-P
President, Medical Management Resources Inc.
Consulting Editor
With the publication of the outpatient prospective payment system/ambulatory payment classification (OPPS/APC) final regulations, the major controversy over required matching of the emergency department (ED) physician evaluation and management (E/M) level to the ED facility level was resolved with this statement, Therefore, we would not expect to see a high degree of correlation between the code reported by the physician and that reported by the facility.
The challenge to hospitals now will be to revise the existing facility assessment criteria that will crosswalk to the emergency department evaluation and management HCPCS codes in such a way that the full range of acuity managed by the nursing staff is reasonably reflected.
The final rule clearly states, We realize that while these HCPCS codes appropriately represent different levels of physician effort, they do not adequately describe non-physician resources. In the same way that each HCPCS code represents a different degree of physician effort, the same concept can be applied to each code in terms of the differences in resource usage. Therefore, each facility needs a system for mapping the services provided or combination of services furnished to the different levels of effort represented by the codes.
First review the content of the CPT emergency department E/M medical decision-making levels to assist coders in determining what facility services generally are provided with each level. This differentiates the various levels of care according to the patients presenting problem, the amount and complexity of data reviewed during the emergency department course, and the risk to the patient from the medical problem.
The four levels of decision-making straightforward, low complexity, moderate complexity and high complexity correspond to a certain level E/M code. Level-one and -two E/M codes, for example, require straightforward medical decision-making, whereas level-three codes require low complexity; level-four codes, moderate; and level-five codes, high complexity.
In essence, the emergency departments as managed by the nursing staff will be a key element in establishing the revised facility criteria for the crosswalks to the HCPCS billing codes.
Do A Self-audit
The revision of this criteria and the uniform use by all emergency department, coding and billing personnel will be critical to the future reimbursement for emergency services under APCs. The Health Care Financing Administration (HCFA) outlines in the final rule that billing information that hospitals report during the first years of implementation of the outpatient prospective payment system (OPPS) will be vitally important to the revision of weights and other adjustments that affect payment in future years.
HCFA will hold each facility accountable for following its own system for assigning the different levels of HCPCS codes and expect to see each facility follow its own rules. Therefore, auditing the code assignment for emergency [...]
