Procedures shouldn’t be part of level determination

ED managers should avoid evaluation and management (E&M) level decision matrix or scoring tools that use ED procedures (intravenous lines, injectables, laceration repairs, or ancillary tests) as part of their level determination, says Marty Karpiel, MPA, FACHE, FHFMA, president of Karpiel Consulting Group in Long Beach, CA.

The Centers for Medicare & Medicaid Services (CMS) raised concerns in 2003 that many of the decision matrix or E&M scoring tools allowed counting of separately paid services in determining a service level, he says.

CMS stated that the level should be determined by resource consumption that is not otherwise separately payable, Karpiel notes. "For example, X-rays are separately payable and, therefore, they should not be one of the variables considered in determining E&M level," he explains.

However, if an RN accompanies an acute patient on a monitor to have a computed tomography (CT) or magnetic resonance imaging (MRI), that is a resource not separately billable and can be used in determining the E&M Level.

The following is a sample list of resources that can count toward E&M level, according to Karpiel:

  • triage level;
  • combative/confused/level of consciousness changes;
  • pre-hospital care provided/directed;
  • special teaching/interpretation/emotional care;
  • nursing assessment basic, intermediate, complex;
  • discharge instructions (minimal, complex);
  • per os/topical/rectal/sublingual medications;
  • admission/transfer workup;
  • crutch training;
  • nursing monitored transports (MRI/CT/unit).

"Hospitals should evaluate their E&M level decision matrix or scoring tools to ensure they are complying with the CMS interpretation of appropriate resources," Karpiel adds.