Single Source Physician and Facility Emergency Room Coding: What Key Elements to Consider

In the continuous pursuit of improved efficiencies, can single-source coding be a solution?

As organizations continue to evaluate the most efficient and cost-effective ways to streamline operations, there is increasing movement toward single-source physician and facility emergency room coding. This has proven to be a successful endeavor for many organizations, though making the shift requires a well-thought-out plan, and openness to change across departments. 

Services rendered in the ED are a mixed bag, from treatment of chest pain to triaging for inpatient admission, with even more complexity if an organization is a trauma center. Advancements in technology and a continuous need for coders, combined with the movement to various value-based payment models, have prompted organizations to look at the bigger picture and re-evaluate operational processes. Considering the continuously increasing volume of outpatient encounters and the need for cost savings, a more holistic approach is needed when evaluating opportunities to improve quality of care, documentation, billing, and reimbursement. Streamlining processes through leveraging technology and using one source for coding hospital and physician services can deliver improvements on a multitude of levels. Some health organizations have claimed a 70 to 80 percent increase in productivity, with an increased clean claim rate and decrease in denials. Single-source physician and facility emergency room coding is being explored in the ED, as well as in special procedures and ambulatory surgery departments.   

Codes for hospital services capture the complexity of care provided within the facility. The procedural service codes may be generated from the chargemaster, coded by a coder, or applied by computer-assisted coding (CAC) technology. Professional coding represents the condition directly related to the treating physician. In theory, if a facility claim is compared to the professional claim, the diagnosis coding should match. However, often this does not happen, which is attributed to various reasons, such as technology, documentation, a coder’s skill level, etc.  

There are four main components of emergency coding: diagnosis, CPT®, modifier(s), and governmental regulation. The methodology for applying these four components may vary by setting; understanding the application of these will allow for solid execution.

Diagnosis coding for the facility provides a comprehensive representation of the condition(s) treated within an ER, regardless of the treating physicians. The professional fee diagnosis coding only represents the diagnoses directly related to the treating physician.  

For professional coding, there are four general aspects of evaluation and management: medical necessity, history of present illness, physical exam, and medical decision-making. CPT codes for facility coding represent a comprehensive clinic encounter; professional codes are representative of the physician’s treatment of the patient. This may require an evaluation and management (E&M) code or a CPT code. Although some of the main coding elements can be the same (CPT, evaluation and management), the methods by which they are applied are different. 

Modifiers are applied both on the facility and the professional side. The facility side is comprehensive, but the professional side represents the views of the physicians involved. The rules for applying a modifier are different for facility versus professional coding. The depth and breadth of a coder’s skill set are paramount when evaluating a single-source coder. 

We are moving closer and closer to a reimbursement system that recognizes both physician and hospital efforts in a single payment structure. In regards to government regulations, currently there are different regulations, in addition to compliance standards. With the implementation of the Outpatient Prospective Payment System (OPPS), or Ambulatory Payment Classifications (APCs), E&M coding was implemented. This new ruling continues to be under evaluation, with liberal guidance in place.

To integrate facility and professional coding into one source, you must identify both consistencies and differences among the facility department and the physician group, noting complexities of service. Although the ED is a fast-paced environment with a diverse mix of services, the diagnoses and treatments rendered in the ED are highly consistent. 

Compatible goals are also essential in combining the facility and professional side into a single source. The two areas have worked separately for a long time. Often, physician coders are specialized, with differing skill sets and certifications. On the other hand, facility coders are generally not specialty-specific. Both areas must be open to change, with stakeholders promoting change to create an engaging environment, which leads to a successful project.  

The results of moving to single-source physician and facility emergency room coding process represents not merely cost savings, but higher quality of care and improved patient experience. By leveraging data and technology, the healthcare sector and its social care partners have an opportunity to improve the efficiency, effectiveness, and sustainability of efforts that address health-related social needs as a regular component of healthcare delivery.

Programming Note:

Listen to Susan Gatehouse report this story live during Talk Ten Tuesday today, 10-10:30 a.m. EST.