Principles for Emergency Department Coding Guidelines
by Tedi Lojewski, RHIA, CCS
Since the implementation of the Outpatient Prospective Payment System (OPPS), the Centers for Medicare and Medicaid Services (CMS) has required hospitals to report facility resources for emergency department (ED) visits using CPT evaluation and management (E/M) codes.
However, CMS recognized that CPT E/M codes do not adequately describe the intensity and range of ED services by hospitals because they reflect physician activities. Therefore, CMS instructed hospitals to develop their own internal guidelines for reporting E/M visits. This article outlines principles for hospital ED visit guidelines, as well as guidance on reporting them.
Four Basic Models
Two of the best known models for ED visit levels are the AHA/AHIMA Guidelines and the American College of Emergency Physicians ED Facility Level Coding Guidelines (ACEP Guidelines). During its consideration of various available guidelines, CMS identified four basic models in use:
ED Visit Guiding Principles
Regardless of the model, guidelines should reflect the hospital resources used in providing the service. CMS recognizes that the E/M level reported by the hospital will not necessarily equate to the level reported by the physician for physician services provided for the same encounter. “Therefore, facilities should code a level of service based on facility resource consumption, not physician resource consumption. This includes situations where patients may see a physician only briefly, or not at all.”1
CMS makes clear that hospital guidelines must reasonably relate the intensity of hospital resources to the levels of effort represented by the codes.
While the healthcare industry continues to operate without national guidelines, CMS expects that each hospital’s internal guidelines should:
Separately Payable Procedures
In its evaluation of the available models, CMS found some systems too complex and overburdensome, susceptible to variability, and subjective in interpretation of guidelines. It also found that all proposed guidelines allow for counting of separately paid services (e.g., intravenous infusion, x-ray, EKG, and lab tests) as interventions or staff time in determining a level of service.
CMS stated that the “level of service for emergency and clinic visits should be determined by resource consumption that is not otherwise separately payable.”2 It expressed concerns that the ACEP model allowed counting of separately payable services, which could result in double counting of hospital resources and subsequent duplicate payment.
In the 2008 OPPS final rule, CMS reconsidered this position and seems to have taken a step back, stating, “In the absence of national visit guidelines, hospitals have the flexibility to determine whether or not to include separately payable services as a proxy to measure hospital resource use that is not associated with those separately payable services.”3 Hospitals must be able to substantiate any decision to include otherwise separately payable services as a determining factor in the ED level assignment and be able to clearly articulate why those services reflect a proxy for additional hospital resource consumption.
Reporting ED Procedures and Modifier -25
Hospitals have increased their internal monitoring of modifier -25 because of the Office of Inspector General’s emphasis on correct -25 assignment and increased activity by the Department of Justice to review hospital billing practices related to the modifier’s use.
As defined by CPT-4, modifier -25 indicates a significant, separately identifiable E/M service by the same provider on the same day of a procedure or other service. The ED is a location where primarily unscheduled, urgent, or emergency care is provided, and modifier -25 use is legitimately higher in the ED than in other outpatient hospital settings.
CMS Transmittals A-00-40 and A-01-80 clarified the appropriate use of modifier -25 under OPPS. To append modifier -25 appropriately to an E/M code, the service provided must meet the definition of a “significant, separately identifiable E/M service” as defined by CPT. It is appropriate to append modifier -25 to ED codes 99281–99285 when these services lead to a decision to perform diagnostic or therapeutic procedures.
Transmittal A-00-40 states that Medicare requires modifier -25 “always be appended to the emergency department E/M codes when provided.”4 However, the Outpatient Code Editor only requires the use of modifier -25 when the E/M service is reported with a procedure code with a status indicator of S or T.
The transmittal further clarifies that it is acceptable to report modifier -25 in conjunction with procedures that are not status S or T, if the E/M service meets the definition of a significant and separately identifiable service. It would not be appropriate to append modifier -25 to the E/M code in cases where the E/M code is the only code on the claim.
The Critical Care Controversy
In the 2008 OPPS final rule, CMS again stated that hospitals must provide a minimum of 30 minutes of critical care services in order to report CPT code 99291, Critical care evaluation and management of the critically ill or critically injured patient; first 30–74 minutes. The response to CMS frequently asked question 8809 states that hospitals must follow the CPT instructions related to CPT code 99291. Any services that CPT indicates are included in the reporting of CPT code 99291 should not be billed separately by the hospital.
CMS also addressed the policy during a hospital open door forum last winter, reiterating that CMS follows CPT-4 guidelines to the extent possible and that critical care coding rules in the CPT-4 manual apply to hospitals and physicians.
Hospitals should thus subtract from the critical care time any separately reportable procedures, such as CPR and drug administration. They should not report separately those procedures included in the CPT definition of critical care. Hospitals also should report face-to-face critical care time provided by physicians or hospital staff. If multiple staff members or physicians are providing the service simultaneously, the time involved can only be counted once.
The HIM Professional’s Role
Eight years later, hospitals continue to develop their own internal guidelines for reporting ED facility visits. The challenge is daunting, and the impact on compliant billing practices is broad. CMS expects hospitals to maintain, update, and provide ongoing education to their providers regarding the internal guidelines they have developed, while following the principles delineated above.
Medical record documentation must support the services billed, based on the hospital’s established internal coding guidelines. HIM professionals play a pivotal role in the development, education, and execution of their hospital’s internal policies. HIM professionals must be advocates for compliant reporting of ED E/M services and act as a resource for the most accurate information under the current regulatory environment.
American College of Emergency Physicians. “ED Facility Level Coding Guidelines.” Available online at www.acep.org/practres.aspx?id=30428.
Centers for Medicare and Medicaid Services (CMS). “Draft Visit Guidelines for Hospital Outpatient Care.” June 1, 2006. Available online at www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/CMS1506P_Draft_AHA_AHIMA_Guidelines.pdf.
CMS. Medicare Claims Processing Manual. Publication 100-04. Available online at www.cms.hhs.gov.
CMS. “OPPS Guidance on Visit Codes.” Available online at www.cms.hhs.gov/HospitalOutpatientPPS/downloads/OPPS_Q&A.pdf.
CMS. “Use of Modifier -25 and Modifier -27 in the Hospital Outpatient Prospective Payment System (OPPS).” Transmittal A-01-80. June 29, 2001. Available online at www.cms.hhs.gov/Transmittals/downloads/A0180.pdf.
“Hospital Coding and Payment for Visits.” Federal Register 72, no. 227 (Nov. 27, 2007): 379–409. Available online at www.access.gpo.gov/su_docs/fedreg/a071127c.html.
Hospital Evaluation and Management Coding Panel of the American Hospital Association and AHIMA. “Recommendation for Standardized Hospital Evaluation and Management Coding of Emergency Department and Clinic Services.” June 24, 2003. Available online at www.ahacentraloffice.org/ahacentraloffice/images/EM_Coding_Report2.pdf.
“Update on Hospital Clinic and Emergency Department Visit Coding.” AHA Coding Clinic for HCPCS 7, no. 4 (fourth quarter 2007).
Tedi Lojewski (firstname.lastname@example.org) is coding compliance senior manager for CHAN Healthcare Auditors in St. Louis, MO, and cochair of the Colorado Health Information Management Association Data Quality Committee.