Transcript ED Coding – Facility vs. Professional: It`s Different!

ED Coding –
Facility vs. Professional:
It’s Different!
GeBBS Healthcare Solutions
Scope
It is important for coding professionals to understand the type
of setting for the codes they are reporting.
Facility fee coding
• Use of the room,
lights, nursing staff,
overhead costs for the
facility
Professional fee coding
• Complexity and
intensity of providers
work, including
cognitive effort
expended
“Facility coding guidelines are inherently different from
professional coding guidelines” - ACEP
Professional Fee Coding
• Evaluation & Management codes were developed in 1992
• Congress established clear criteria (Documentation
Guidelines) in 1995, additional revisions were introduced
in 1997
• Documentation guidelines (DG) recognize seven (7)
components, three (3) of which are key components
• History
• Examination
• Medical Decision Making
Professional Fee Coding
• New patients require all three (3) of the key components
to meet or exceed a level of service
• Established patients require only two (2) of the three (3)
key components to meet or exceed a level of service
• No distinction is made between new and established
patients in the emergency department
• Time is not considered a component for professional fee
Evaluation & Management coding in the emergency
department
Facility Coding Guidelines
•
Since the implementation of the Outpatient Prospective Payment
System (OPPS), the Centers of Medicare and Medicaid Services
(CMS) required hospitals to report resources for emergency
department visits using Evaluation & Management (E&M) codes.
•
There is currently no national standard coding guidelines for
facility E&M coding.
•
CMS instructed hospitals to develop their own coding guidelines
• “Guidelines must reasonably relate the intensity of hospital
resources to the levels of effort represented by the codes”
Facility Coding Guidelines
•
CMS recognizes that the E/M level reported by the hospital will
not necessarily match to the level of service reported by the
physician for professional 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.”
Facility Coding: Four Basic Models
• CMS identified four (4) basic models in use when determining
facility levels;
• Number or type of staff interventions
• Time
• Point system
• Patient severity
• Two of the most commonly used models for Emergency
Department visit levels are the AHA/AHIMA Guidelines and the
American College of Emergency Physicians ED Facility Level Coding
Guidelines (ACEP Guidelines).
Facility Coding: Four Basic Models
• Number or type of staff interventions
• Intervention models use basic care interventions to report the lowest
level of service, with higher levels assigned as complexity or number of
nursing and ancillary staff interventions increases.
• AHA/AHIMA Guidelines and the ACEP Guidelines fall into this
category.
• Time
• As time spent with the patient increases, so does the level assigned.
• Point system
• The time, complexity, and type of staff required determine the number of
points assigned to each intervention.
• Patient Severity
• The diagnoses, level of medical decision making, and presenting
complaint or medical problem are used to correlate resource
consumption.
Eleven Criteria
OPPS lists eleven (11) criteria that must be met for facility billing
guidelines.
• 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.
• The coding guidelines should be based on hospital facility
resources. The guidelines should not be based on physician
resources.
• The coding guidelines should be clear to facilitate accurate
payments and be usable for compliance purposes and audits.
• The coding guidelines should meet the HIPAA requirements.
Eleven Criteria
• The coding guidelines should only require documentation that is
clinically necessary for patient care.
• The coding guidelines should not facilitate upcoding or gaming.
• The coding guidelines should be written.
• The coding guidelines should be applied consistently across
patients in the clinic or emergency department to which they
apply.
• The coding guidelines should not change with great frequency.
• The coding guidelines should be readily available for fiscal
intermediary (or, if applicable, MAC) review.
• The coding guidelines should result in coding decisions that could
be verified by other hospital staff, as well as outside sources.
Same patient: Different codes
• Patient presents to the
Emergency Department
with a stiff neck and
headache. An EPF history,
EPF examination is
performed. Flexeril PO
given for pain. Labs, MRI
and a Lumbar puncture is
ordered and performed.
Provider:
•
•
•
99283
History: EPF
Examination: EPF
MDM: Moderate Complexity
Facility:
99285
Staff intervention model
• Initial assessment
(1)
• Prescription medications
administered PO
(3)
• Preparation of three diagnostic
tests
(5)
• Prep/assist with lumbar puncture
(5)
Slide 11
Thank You!
Cara Friederich
310.751.9567
[email protected]
Slide 12