Differentiating Between Professional and Facility ED Coding

It is important to differentiate between ED professional and ED facility coding, and how levels of service are assigned.

EDITOR’S NOTE: Recently, RACmonitor published articles referencing UnitedHealthcare/ Optum’s notice that they were changing the way they process emergency department (ED) claims, beginning April 1, 2020, along with how professional and facility levels of service are being selected.

ED professional codes are typically assigned by professional coders with specialized training in emergency medicine coding. The CPT® code set, including ED code descriptors and applicable rules, guide this choice based on the documented history, physical exam, and medical decision-making, as indicated by the chief complaint and the nature of the presenting problem. In addition, the 1995 Medicare documentation guidelines and CPT coding principles are considered in the code assignment. The Centers for Medicare & Medicaid Services (CMS) 1997 guidelines specialty exams may be used, but they rarely apply to ED visits. The Marshfield Clinic guidelines may also be used to codify the key components of selecting an evaluation and management (E&M) code.

Emergency medicine relies on professional coders more than many other specialty, due to the workflow inherent. In most ED practices, the emergency physician treats the patient and documents the encounter. It then falls to the professional coder to assign the appropriate codes based on the documentation in the chart – as opposed to the private practice, wherein the physician usually selects their own codes, which may then be reviewed and verified by the in-house coder (but the lion’s share of the coding decisions are made by the physician). ED coders tend to get more specialized and ongoing training than those working in most other medical specialties. One reason is the wide range of medical conditions that must be managed by emergency physicians daily, and varied types of treatments an emergency physician might perform. Whether it be a heart attack or car accident, fracture care or a fever, eye injuries or delivering a baby, the emergency physician and the emergency coder must be able to deal with all of them with a level of precision and expertise that leaves little room for error. Most ED professional coders are subjected to rigorous and frequent internal and external audits. Any coder with less than near-perfect compliance must undergo additional training to reach the higher standard.

The CPT Editorial Panel has recently considered and approved new documentation guidelines, to be effective in 2021; however, those guidelines apply only to new and established office visits. They will not be applicable to ED E&M services.

While it is correct that CMS has never released or endorsed any national guidelines for ED facility coding, it is not correct to say there are no national standards that are widely followed.

CMS has given hospitals direction in the form of general guidelines, including the following:

1. 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.
2. The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources.
3. The coding guidelines should be clear to facilitate accurate payments, and be usable for compliance purposes and audits.
4. The coding guidelines should meet HIPAA requirements.
5. The coding guidelines should only require documentation that is clinically necessary for patient care.
6. The coding guidelines should not facilitate upcoding or gaming.
7. The coding guidelines should be written.
8. The coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply.
9. The coding guidelines should not change with great frequency.
10. The coding guidelines should be readily available for fiscal intermediary (or, if applicable, Medicare Administrative Contractor, or MAC) review.
11. The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.

Regarding proposals to use the final diagnosis as a proxy for medical necessity, that methodology does not work well in the emergency department setting. Patients frequently present with symptoms that mimic serious conditions, such as heart attack or stroke, which require multiple diagnostic tests to determine the presence or absence of an emergency medical condition. In fact, the recently updated American Medical Association (AMA) CPT guidelines state that “the final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.” This is not just good medicine; it is the law, as codified in the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA), to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.It is unfair to refuse payments for service provided in good faith, based on presenting conditions and required by law.

Further, the prudent layperson standard, adopted individually by most states, defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: a) placing the patient’s health in serious jeopardy; b) serious impairment to bodily functions; or c) serious dysfunction of any bodily organ or part. The Patient Protection and Affordable Care Act in 2010 also extended the Prudent Layperson Standard even further to individual and small-group health plans, and to self-funded employer plans.

A payer using proprietary “black box” software determining the “correct” level of service based only on a patient’s age and final diagnosis, without review of the chart documentation, would appear to be in violation of the prudent layperson standard.

Lastly, many patients with legitimate health concerns try to seek care from their primary care providers or other sites of service, but are forced to come to the ED because of lack of access to alternative sites of care in a timely manner. This is true not only of nights, weekends, and holidays, but also when the next available appointment with an established provider is still weeks away from the current need for care. Cleary, not all of those presentations are of high acuity, but they also should not be denied for payment based on consideration of just the final diagnosis. Sadly, many health plans do just that. The result is that more and more patients seek other sites of service for care of their less serious medical conditions, and only come to the ED for high-acuity presentations. This has resulted in a shift in most ED frequency distributions to be dominated by the Level 4 and 5 ED E&M codes.

It is also incorrect to propose that every Level 5 ED patient would expect to be admitted as an inpatient. In fact, just the opposite is true. Advances in treatment are such that many presentations that would have automatically triggered hospital stays even 10 years ago can be diagnosed, treated, and stabilized during an ED encounter or observation stay. Most insurance companies aggressively try to avoid inpatient admission if quality care can be provided in an outpatient site of service. A patient with a serious medical condition such as acute exacerbation of asthma, croup, or anaphylactic shock, can be diagnosed, treated, and stabilized by a skilled emergency physician to the point of safe discharge for appropriate follow-up, without the need for costly inpatient admission. Avoiding a hospital stay is generally considered a good and desirable outcome, by both patients and payors.

Emergency departments serve as the healthcare safety net for the nation, being available 24/7/365 and fully staffed and ready to take all patients, regardless of their ability to pay. This is a very expensive commitment, so fair payment and adjudication of claims must be made to continue access to high-quality emergency care for all of us when we need it the most.