What should EDs be worried about?

The proposed Medicare billing regulations raise several concerns in emergency medicine.

"The ED will be swept in with other outpatient services. So we need to look at the global picture to see if we are being mistreated," says Mason Smith, MD, FACEP, president and chief executive officer of Lynx Medical Systems, a Bellevue, WA-based consulting firm specializing in coding and reimbursement for emergency medicine. (See excerpt from the American College of Emer gency Physicians’ comments on the proposed regulations, p. 91.)

Consider these eight primary areas of concern for the ED:

1. Diagnosis vs. symptom-based payment. The biggest concern is that the Health Care Financing Administration (HCFA) will decide to base payment on patients’ eventual diagnoses instead of their presenting symptoms, reports Charlotte Yeh, MD, FACEP, medical director for Medicare policy at the National Heritage Insurance Co. in Hingham, MA.

"If payment is diagnosis-based, it would be very hard to figure out the cost of providing service because people have so many presenting complaints and symptoms," Yeh says.

2. Coding for services.

There are currently five levels of current procedural terminology (CPT) physician billing codes, but it is still unclear whether the existing CPT codes will be used to develop the APCs.

"The APCs should be based on existing CPT defin itions, using CPT methodology to base pricing on actual work performed," Yeh emphasizes. The alternative is developing APCs by diagnosis, which would be problematic, she says.

Another possibility is to use existing CPT levels of service plus a critical care code. "That would identify those patients who get critical care services but end up not being admitted, either because they died or were transferred to a new facility," she explains.

3. Reimbursement for observation services.

Medicare is likely to cease reimbursement for ED observation services, says Smith. "Hospitals can continue to provide the service, but it is unlikely that Medicare will provide any financial incentive to the hospital to develop this service," he notes.

This change means that no separate payment will be made for observation services in the ED. "According to the published rules, observation services will be bundled with emergency medicine visits," says Smith. "This will result in the elimination of incremental payment to hospitals for patients placed in observation status after an ED visit."

ACEP wants recognition for ED observational services because they are often a more cost-efficient way of caring for patients. "If that is not recognized by HCFA, then the only option will be to admit patients to the hospital," Yeh says.

4. Fees for medical screening exams.

HCFA is proposing a medical screening fee for evaluations required under the Emergency Medical Treatment and Active Labor (EMTALA). "The concern about that is that the exam is broadly defined as whatever is required to determine the presence or absence of an emergency," she says.

Identifying a single fee may be risky if it translates into a single payment without recognizing the full range of services EDs have to cover, Yeh explains. "The screening exam may include a wide range of services, from simple to complex."

5. Volume disincentives.

If patient volumes increase, the payment schedule may decrease, warns Yeh. "So if they see your volume increasing, you may find yourself penalized for being the safety net for the community. In emergency medi cine, we don’t have control over volumes, and all you need is one flu epidemic to dramatically increase volumes."

6. Defining ED property.

The regulations address the definition of ED property. "HCFA is defining it to include the driveway and sidewalks. That is basically taking the EMTALA guidelines and extending them even further, which is a concern," she says. "This section is only two paragraphs out of 400 pages, so it is easily overlooked, but it could be very problematic."

The section was included in response to the controversial incident at Chicago’s Ravenswood Hospital in May, when ED staff, citing hospital policy, refused to help a 15-year-old gunshot victim lying less than a block from doors of the ED, he says. Police finally dragged the boy inside the hospital, but he soon died.

The ED property definition could cause serious problems for EDs, says Michael Bishop, MD, FACEP, vice president of the American College of Emergency Phy si cians in Dallas. "We in emergency medicine feel we should take care of everybody that comes to the ED. But to use a silly example, what if you had a rural hospital that owned 200 acres and somebody was hunting in the far corner of that property and sprained an ankle? Would the ED be responsible?"

The regulation also defines "the hospital" as anything the hospital owns, which could include a large campus or remote facilities, he says.

7. Competitive issues.

Depending on the percentage of Medicare patients and what the actual payment levels turn out to be, there could be a major impact on EDs in competitive areas. "If HCFA uses a diagnosis-based fee schedule, and one ED is a trauma center and the other is a cardiac center, it could cause major shifts in payments without a change in population," Yeh says.

8. Decreased level of care.

Depending on adequacy of payment and how payment groups are defined, the new rules could cause EDs to provide less care in order to have a higher return. "If fees are not based on how much service you’ve provided, and are instead based on diagnosis, you might find hospitals trying to attract the better diagnosis cases and doing less care for higher cost," she says. n

Here are ACEP’s main concerns about HCFA rules

The following is an excerpt from the Dallas-based American College of Emergency Physicians’ (ACEP) commentary on the Health Care Financing Administration’s (HCFA) proposal. The proposed regulations will change outpatient reimbursement for hospitals into a system that uses ambulatory patient classifications (APCs).

4 "ACEP strongly recommends that HCFA rely exclusively on CPT [current procedural terminology] evaluation and management codes, without diagnosis codes, to define medical visit APCs.

4 "To improve consistency across sites of service, ACEP believes that hospital outpatient clinics and ED services should be treated similarly to office-based outpatient services. The Medicare fee schedule does not consider diagnosis for practice expense payment in the office or non-hospital sites of service; therefore, neither should diagnosis codes apply to the ED setting.

4 "ACEP recommends that, for ED services, HCFA establish five visit APCs, in addition to the proposed critical care APC. These new APCs should be based on the five existing CPT definitions for ED evaluation and management levels.

4 "ACEP supports HCFA’s recommendation to utilize critical care as a separate APC that can be assigned to ED patients.

4 "ACEP supports the concept of establishing a uniform level of payment for lower intensity services so that ED payment is consistent with the payment made for similar services in the outpatient clinic.

"In certain communities, where there is limited access to care, use of the ED for unscheduled urgent visits is, in fact, desirable. Often the ED represents the only source of available care of this type in the community. Recognizing this important safety net role of EDs, without increasing costs, is consistent with HCFA’s mission.

4 "ACEP recommends that HCFA create a separate APC for observation services provided in hospital outpatient settings. ACEP also recommends that hospitals be permitted to bill for observation services in addition to ED or clinic services on the same date.

"Providing an outpatient observation APC would recognize the level of work required for outpatient services, above and beyond other services provided to a particular outpatient. These patients require more management than a traditional outpatient visit, but less than would be involved in an inpatient admission.

4 "ACEP recommends that HCFA reclassify cardiac and cerebral thrombolysis from status C (inpatient only) to a valid procedure for outpatient services.

"Although the majority of the patients that require this therapy will be admitted to a hospital, many patients will be transferred to another facility for admission. Some patients may also expire after therapy but before admission. Medical necessity for thrombolysis requires immediate treatment. Therefore, the procedure necessarily can and will occur in the outpatient setting (e.g., emergency department) prior to admission or transfer arrangements being made.

4 "Creation of a unique code for a medical screening examination (MSE) violates the EMTALA regulations. Essentially, the MSE encompasses a full range of services from simple to complex. Therefore, use of existing evaluation and management codes has a number of benefits. These codes are familiar, with known definitions, and reflect the range of MSE services more accurately.

"The regulations do not contain a specific definition of a MSE. This would lead to local carrier/intermediary definitions, which could vary widely around the country. Such a variation in definitions would lead to dramatically non-uniform coverage of such examinations.

4 "EMTALA expansion should be limited to those hospital entities that hold themselves out to provide emergency services.

"Although ACEP endorses the clarification of the anti-dumping language to include parking lots, sidewalks, and driveways of the hospital campus, we are concerned about how this might be interpreted. The ED staff are obligated to those patients in the ED and should not be required to abandon that setting to provide care for patients in other parts of the campus. Some mechanism must be developed to achieve the stated purpose of providing a MSE without compromising the ongoing care in the ED.

4 "ACEP strongly urges HCFA to entirely withdraw the behavioral offset adjustment, if not in total, then at least for services provided in the ED.

"Hospitals do not determine, nor can they control, the number of patients, including Medicare patients, who present for treatment to their EDs. A behavioral offset would not address any behavior seen in the ED, and will undermine the critical safety net role that EDs provide to the community.

"EMTALA prohibits the ED from turning any patient away. EMTALA requires that every patient who presents to the ED must receive a complete MSE.

"There are many unpredictable factors, such as en demic infectious disease, severe weather conditions, or even acts of terrorism, that govern use of the ED rather than anything under the hospital’s control. Use of a be havior offset would penalize the ED for the vital safety net and access of last resort roles the ED fulfills."