ED Coding Update

Prepare for more monitoring of quality performance

[This quarterly column on coding in the ED is written by Caral Edelberg, CPC, CCS-P, CHC, president of Edelberg Compliance Associates, Baton Rouge, LA. If there are coding issues you would like to see addressed in this column, contact Edelberg at phone: (225) 454-0154. EFAX: (225) 612-6904. E-mail: caral@cedelbergcompliance.com.]

Although the Centers for Medicare & Medicaid Services (CMS) made several minor modifications to the Outpatient Prospective Payment System (OPPS) for 2010 with impact on the emergency department, none result in a significant change in ED facility coding. However, there are references to several planned projects required to provide data to be used in future reporting and/or rate changes.

With that in mind, it's a good time to rethink and revise how we look at many of the components of our ED facility coding and prepare for increasing monitoring of quality performance for coding and medical care:

ED visit levels.

CMS has no plan to create national ED visit-level criteria. The agency notes that the current distribution and content of internal guidelines result in a relatively normal national distribution of ED visits. CMS has observed a consistent pattern that distinguishes the different levels of service, which is good news for EDs in general. In addition to the visit levels, CMS reconfirms that hospitals should continue to report all HCPCS codes for services rendered by following correct coding principles, CPT code descriptions, and additional CMS guidance. CPT code descriptions that refer to the term "physician" do not restrict the reporting of the code or application of policies to physicians only, but also applies to all practitioners, hospitals, providers, and suppliers.

Good news regarding MAC/RAC audits! Although CMS continues to encourage FIs (fiscal intermediaries) and MACS (Medicare administrative contractors) to review each hospital's internal guidelines for evaluation and management (E/M) level assignment when the facility is audited, there are currently no RAC (recovery audit contractor) activities planned for E/M services. RAC auditors are required to audit only CMS-approved issues. It's a good idea to monitor your RAC auditor, however, for current audit hot spots.

Although CMS officials continue to believe hospitals do a good job with developing and following their ED facility assessment criteria (E/M levels), they intend to begin tracking the most common diagnoses associated with the Type A and Type B ED visits for review by the ambulatory payment classifications (APCs) panel. This analysis is planned to include hospital-specific characteristics in addition to analysis of the CY 2008 claims data for Type A and Type B ED visits. Based on CY 2008 data, which are the most recent available, CMS identified 344 hospitals that billed at least one Type B ED visit, with total frequency of Type B visits at 220,000. All but five of the 344 hospitals reporting Type B visits also reported Type A visits. Interestingly, most reported only Type A ED visits: 3,238 total hospitals. The total frequency of visits provided in Type A EDs in 2008 was about 11.6 million.

What do these numbers mean for hospital reporting in 2010? As CMS plans to track and compare diagnoses to E/M levels, it's a good time to track that information for your facility to identify any outliers and ensure that your facility criteria are performing as intended. In addition, physicians need to be reminded that assignment of diagnosis codes reflect the physician documentation noted on the record. Thus, incomplete documentation results in diagnosis coding that might not fully support the medical necessity and medical problems managed during the patient's ED stay. Furthermore, ED physician documentation is used for "present-on-admission" indicators necessary for the inpatient coding when patients are admitted through the ED. It looks as if we will be seeing increasing focus on diagnosis coding to support the services we perform, and the data will be available to support future payment decisions.

Critical care.

CMS reiterates its previous directives on critical care, particularly relating to time. Facility critical care may only be billed for ED services if 30 minutes or more of critical care services are provided consistent with the facility's internal guidelines. Fewer than 30 minutes is billed with the E/M level that most closely defines the service.

For those patients who expire in the ED while receiving critical care, hospitals are instructed to continue use of the –CA modifier for procedures on the OPPS inpatient list used to resuscitate or stabilize a patient with an emergent, life-threatening condition who dies before being admitted.

With regard to trauma team response, CMS continues to require 30 minutes or more of critical care in addition to the 0390 trauma team activation code as "it would be extremely unusual for a patient to require trauma team services, be rushed to surgery within 30 minutes of arrival in the emergency department, and not be subsequently admitted to the hospital as an inpatient" [74 Fed Reg 60,551 (Nov. 20, 2009)].

"Triage-only" visit.

ED coding staffers continue to question how to bill ED services when the patient is seen only by a nurse for triage but leaves prior to being seen by a physician. CMS does not specify the type of hospital staff who may provide services in hospitals, as OPPS makes payment for services incident to physician services — that is, for the services and resources used to support physician services. Remember, OPPS is for the ED staff support, not the ED physician services, which are billed separately. Hospitals may choose their own staffing configurations to provide services as long as the following also are taken into account:

  • state and local laws;
  • hospital policies;
  • federal requirements (EMTALA and Medicare conditions of participation for hospital staffing).

CMS clarifies that billing a visit code in addition to another service because the patient interacted with hospital staff or spent time in a room for the service is inappropriate. However, here's where it gets specific to the facility: "A hospital may bill a visit code based on the hospital's own coding guidelines which must reasonably relate the intensity of hospital resources to different levels of HCPCS codes." CMS published a visit FAQ that further clarifies: "Providers should work with their local FIs regarding the medical necessity for these visits." Thus, it would seem that if facility nursing criteria specify the type of staff support required to triage a patient and rule out the presence or absence of a medical emergency, a low-level visit level might be appropriate. [Editor's note: The quality data reporting program for hospital outpatient care, known as the Hospital Outpatient Quality Data Reporting Program (HOP QDRP), generally has been modeled after the program for hospital inpatient services. See the story, below.]


For assistance with monitoring recovery audit contractor (RAC) auditors for hot spots, contact:

HOP QDRP modeled after inpatient program

By Caral Edelberg, CPC, CCS-P, CHC
Edelberg Compliance Associates
Baton Rouge, LA

The quality data reporting program for hospital outpatient care, known as the Hospital Outpatient Quality Data Reporting Program (HOP QDRP), generally has been modeled after the program for hospital inpatient services. Both of these quality reporting programs for hospital services, as well as the program for physicians and other eligible professionals, known as the Physician Quality Reporting Initiative (PQRI), have financial incentives for reporting of quality data to CMS. In 2009, CMS required that hospitals paid under the OPPS submit data on seven measures for hospital outpatient services furnished on or after April 1, 2008. For 2010, CMS has added four new measures for reporting. (See list of HOP QDRP measures for 2010.)

More measures in 2011

In addition to these measures, CMS is considering additional measures for 2011 reporting that will affect the ED and will include two measures that address overutilization of CT scans, which have implications on patient safety due to radiation exposure. Additional information on proposed criteria for ED CT scans for headache, as well as other measures under consideration, can be found at www.imagingmeasures.com.