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Hospital emergency departments encompass both professional and technical services. Codebusters provides coding and auditing services for both the facility claim and physician claim in an ED encounter. Hospitals bill for an ED visit using APCs under the OPPS, whereas physician’s will bill the same visit under the Medicare Physician Fee Schedule. The facility collects a separate payment than the physician, as it does for all facility-based inpatient and outpatient visits. Coding and auditing considerations and procedures differ for each of ED facility and physician coding. Professional services coding for the ED has peculiarities that make it different from E/M coding in other settings. ED coding and auditing of facility and professional documentation, coding, and billing can be performed onsite or offsite. |
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The facility or hospital is paid under OPPS, where an APC is assigned for each visit. CMS requires the assignment of a level of service code (EM code), as well as documentation of all procedures in order to assign APC codes for reimbursement. Unlike DRGs, more than one APC code can be assigned per encounter. Coders must be sure to extract all documented physican and nurse procedures, and review all notes to ensure proper documentation of procedures. Diagnosis codes must be present to establish the medical necessity of the visit, as defined by LCDs and NCDs. Proper modifiers must be used when E/M levels and procedures are both coded to ensure correct payment. |
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National guidelines for defining level of service do not exist. CMS has directed hospitals to develop their own guidelines. CMS stated that the “level of service for emergency and clinic visits should be determined by resource consumption that is not otherwise separately payable.” EM code should reflect hospitals resource consumption, not the physicians. Physician and facility EM code may not be the same. Facilities must be sure they are consistently applying justifiable rules for level assignment. All procedures and supplies should be captured by the chargemaster whether separately payable or not. Reviews can be comprehensive or focused. We can review care management compliance and effectiveness, icd9 and cpt coding, documentation by physician and ancillary staff, and billing/charges compliance. |
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