Introduction
The implementation of the Outpatient Prospective Payment System (OPPS) by the Centers for Medicare & Medicaid Services (CMS), formerly known as HCFA, in 1997 marked a significant shift in how Medicare reimburses hospitals for outpatient services. This system, analogous to the Diagnosis Related Groups (DRGs) for inpatient care, utilizes Ambulatory Payment Classifications (APCs) to categorize and pay for facility outpatient services under the Medicare program. It’s crucial to understand that APCs are specific to hospital facilities and do not influence physician payments, which are governed by the Medicare Physician Fee Schedule. For a deeper dive into APCs, resources such as the Frequently Asked Questions on the ACEP (American College of Emergency Physicians) website offer valuable insights.
A fundamental distinction exists between facility and professional coding guidelines. Facility coding is designed to reflect the breadth and intensity of resources a hospital employs in delivering patient care. Conversely, professional coding is based on the complexity and intensity of the work performed by healthcare providers, encompassing their cognitive effort. This inherent difference means there isn’t a direct, one-to-one correlation between facility and professional coding. Consequently, applying one set of derived codes to determine the other on a case-by-case basis lacks a rational foundation. This distinction is key to understanding the nuanced approach to determining the correct Coding Level Of Care in outpatient facilities.
In the 2011 OPPS update, CMS reiterated its stance on “Triage-only” visits, clarifying that the system doesn’t dictate the type of staff who must provide services. Hospitals have the autonomy to establish their own coding guidelines for visit codes, provided these guidelines logically link the intensity of hospital resources to different levels of HCPCS codes. The overarching principles are medical necessity and thorough documentation of the services rendered.
However, a 2012 CMS Facility FAQ brought further clarification, specifying that hospital outpatient therapeutic services and supplies, including visits, must be “incident to” a physician’s service and ordered by a physician or another qualified practitioner. Services delivered by nurses under standing orders do not meet this “incident to” requirement. Diagnostic services, on the other hand, are exempt from the “incident to” rule and can be coded even if a patient leaves without being seen by a physician. This distinction between diagnostic and therapeutic services is important for accurate coding level of care assignment.
Currently, there is no universally mandated national standard for hospitals to assign Evaluation and Management (E&M) code levels for outpatient services in clinics and Emergency Departments (EDs). CMS mandates that each hospital must develop its own facility billing guidelines. These guidelines are expected to meet eleven specific criteria outlined in OPPS (detailed in the APC FAQ). The core principle is that facility billing guidelines should logically correlate the intensity of hospital services with the varying levels of effort represented by the codes. These guidelines must be resource-based, clear for accurate payment processing, require only clinically necessary documentation, and prevent upcoding or gaming of the system. The 2009 CMS Final Rule for facility billing and summaries available on the ACEP website provide further context and details on these requirements.
ACEP has developed facility billing guidelines that it believes are consistent with OPPS principles, offering them as a potential framework. Facilities are advised to evaluate these guidelines to ensure they are appropriate and reflective of their specific institutional context. Some facilities have found it beneficial to adapt these guidelines to their unique needs. The following sections will delve into the ACEP facility coding model, providing a practical methodology for assigning visit levels in the Emergency Department and highlighting how to determine the correct coding level of care.
Instructions for Using the ACEP Facility Coding Model
The ACEP facility coding model is designed as a user-friendly tool for assigning visit levels within the Emergency Department (ED). The guidelines are structured in a table format with three columns. The leftmost column lists the facility codes and their corresponding APC levels, which are justified by the “Possible Interventions” detailed in the middle column. The rightmost column, labeled “Potential Symptoms/Examples which Support the Interventions,” serves as a guide for coders to associate interventions with specific facility code/APC levels. It’s critical to understand that this “Potential Symptoms/Examples” column is not used to determine the appropriate facility code/APC level. The determination is exclusively based on the “Possible Interventions” listed in the middle column.
The “Possible Interventions” column specifically refers to actions taken by the nursing and ancillary staff within the Emergency Department, not interventions performed by emergency physicians. These “Possible Interventions” may include examples of procedures that could be billed separately by the facility. However, these procedure examples are intended to represent the typical intensity of facility services for patients requiring them and are not meant to substitute for or duplicate labor, time, or supplies already included in separately billable procedures. Definitions for different levels of “Discharge Instructions” are provided at the end of these guidelines.
To determine the appropriate facility code/APC level, one must focus on the interventions performed by nursing and ancillary ED staff as listed in the “Possible Interventions” column. If a “Possible Intervention” is listed under a specific facility code level, and no other interventions provided fall into a higher facility code level, then the facility code level corresponding to that intervention is selected. Multiple “Possible Interventions” within the same facility code/APC level may occur during a single visit. Whether there is one or multiple interventions, as long as they all fall within the same level, the assigned facility code level remains consistent. Essentially, regardless of the number of “Possible Interventions” at a given level, the coding level of care is determined by the highest level at which at least one “Possible Intervention” is documented.
In the “Possible Interventions” column, the phrase “Could include interventions from previous (lower) levels, plus any of:” is used. This indicates that, for example, if the highest facility code/APC level justified by any “Possible Intervention” is 99283 (APC level 614), then 99283 is the appropriate facility code. The presence of “Possible Interventions” from levels 99281 and/or 99282 in addition to interventions at the 99283 level does not change the assigned facility code level. The coding level of care, therefore, is always the highest level at which a minimum of one qualifying “Possible Intervention” is identified.
Examples of Applying the ACEP Facility Coding Guidelines
To illustrate the practical application of these guidelines in determining the coding level of care, consider the following examples:
Example #1
A 48-year-old woman with a history of myocardial infarction and atrial fibrillation presents to the emergency department with pelvic pain. She undergoes an initial assessment by the ED nurse and receives tests performed by ED staff, including a stool hemoccult test and a urine dipstick test. An IV saline lock is inserted by the ED nurse, and blood is drawn for laboratory tests. A Foley catheter is inserted by the ED nurse to obtain a urine specimen. The patient is examined by the ED physician, including a pelvic exam (with the ED nurse in attendance). She is prepared for and transported to Radiology by ED staff for a pelvic ultrasound, with cardiac monitoring during transport and the ultrasound procedure. Following test results, the ED physician diagnoses a ruptured ovarian cyst, prescribes analgesics, advises follow-up with her OB-GYN specialist, and recommends rest. The nurse provides “Complex” discharge instructions.
To determine the appropriate facility code, the coder first looks for “Pelvic Pain” in the “Potential Symptoms/Examples” column. While not listed directly, “Abdominal Pain” is present at both the 99284 and 99285 levels. The coder then reviews the “Possible Interventions” at the 99285 level and finds the following interventions that were provided to this patient:
A. Monitoring vital signs of patient during in-hospital transport and testing
B. Discussion of Discharge Instructions “Complex”
Therefore, the appropriate facility code for the services provided is 99285, with a corresponding APC level of 616. This example demonstrates how interventions, not symptoms alone, dictate the coding level of care.
Example #2
A 66-year-old woman in excellent health, taking no medications, comes to the ED with a low-grade fever, dysuria, and urinary frequency. The ED nurse assesses her and performs a urine dipstick test on a specimen obtained via an “in and out” Foley catheterization, as ordered by the ED physician. The physician’s exam reveals a temperature of 101°F (oral) and moderate suprapubic tenderness. The urine dipstick is positive for leukocyte esterase and nitrites. The physician diagnoses “Acute Cystitis” and prescribes antibiotics and analgesics. The nurse administers Pyridium and Sulfamethoxazole/Trimethoprim in the ED and provides “Moderate Complexity” discharge instructions.
The coder reviews the “Potential Symptoms/Examples” column and identifies:
A. Medical conditions requiring prescription drug management
B. Fever which responds to antipyretics
The coder then examines “Possible Interventions” at the 99283 level, corresponding to these symptoms, and finds the following interventions provided:
A. Prescription medications administered PO
B. Foley catheters; In & Out caths
C. Discussion of discharge instructions (Moderate Complexity)
Upon reviewing levels 99284 and 99285, no interventions at these higher levels are found. Consequently, the highest coding level of care achieved is at the 99283 level. Thus, facility code 99283 (APC 614) is assigned.
Critical Care Facility Coding (99291 – APC Level 617)
Assigning the Critical Care code 99291 follows the same principles as the E&M codes 99281-99285. A minimum of 30 minutes of critical care time is required for facility billing.
The administration and monitoring of IV vasoactive medications (such as adenosine, dopamine, labetolol, metoprolol, nitroglycerin, norepinephrine, sodium nitroprusside, etc.) is a strong indicator of critical care and justifies a higher coding level of care.
Example of Critical Care Coding
EMS brings in a 68-year-old man experiencing grand mal convulsions with brief interludes of 1-3 minutes between seizures. He undergoes multiple diagnostic tests, receives 2 mg of Ativan IV followed by a one-hour IV infusion of one gram of Dilantin. His blood pressure is 240/140, which is reduced to 180/110 with an IV infusion of sodium nitroprusside. A CT scan reveals a small acute intracerebral hemorrhage without midline shift. He is transferred to another hospital for neurosurgical care. 45 minutes of Critical Care is documented.
The coder finds “Status-Asthmaticus, Epilepticus” and “Cerebral Hemorrhage of any type” listed under “Potential Symptoms/Examples” for Critical Care. Documentation confirms IV drips of Dilantin and sodium nitroprusside, leading to the identification of the intervention “Multiple parenteral medications requiring constant monitoring” under the “Critical Care” guideline. With 45 minutes of documented Critical Care time and only one qualifying “Possible Intervention” needed for code 99291, the coder assigns Critical Care code 99291 (APC 617). This highlights how specific interventions and time spent directly influence the coding level of care for critical patients.
Definitions for Discharge Instructions
The complexity of discharge instructions is a key factor in determining the coding level of care. Here are the definitions for different levels:
- Straightforward: For self-limited conditions needing no medications or home treatment. Instructions include signs of wound infection and when to return to the ED.
- Simple: Involves over-the-counter (OTC) medications or simple treatments like dressing changes. Patients quickly understand instructions.
- Moderate: Includes head injury instructions, crutch training, limitations on bending, lifting, or weight-bearing, and prescription medication reviews (side effects, reactions). Patients may have questions but show adequate understanding.
- Complex: For multiple prescription medications and/or home therapies with detailed reviews of side effects and reactions. Applies to diabetic, seizure, or asthma teaching in compromised or non-compliant patients. Patients/caregivers may struggle to understand and need extra support for compliance.
Disclaimer
It is important to acknowledge that the ED Facility Level Coding Guidelines provided by the American College of Emergency Physicians (ACEP) are for informational purposes only. While developed by sources believed to be knowledgeable, neither ACEP nor its members warrant the accuracy or completeness of these guidelines. ACEP and its members disclaim liability for damages arising from the use of, reference to, or reliance on these guidelines. These guidelines are not intended as the definitive reference for CMS OPPS coding, which is case-specific and subject to change. Payment policies are determined by CMS, and specific payment-related queries should be directed to CMS. These guidelines serve as a helpful tool in understanding how to approach coding level of care determination, but should be applied with professional judgment and awareness of evolving regulations.
| Facility Charge Assignment | ||
|---|---|---|
| Level | Possible Interventions¹ | Potential Symptoms/Examples which support the Interventions |
| ICPT 99281Type A: APC 609Type B: APC 626HCPCS: G0380 | Initial AssessmentNo medication or treatmentsRx refill only, asymptomaticNote for Work or SchoolWound recheckBooster or follow up immunization, no acute injuryDressing changes (uncomplicated)Suture removal (uncomplicated)Discussion of DischargeInstructions (Straightforward) | Insect bite (uncomplicated)Read Tb test |
| IICPT 99282 Type A: APC 613Type B: APC 627HCPCS: G0381 | Could include interventions from previous levels, plus any of:Tests by ED Staff (Urine dip, stool hemoccult, Accucheck or Dextrostix)Visual Acuity (Snellen)Obtain clean catch urineApply ace wrap or slingPrep or assist w/ procedures such as: minor laceration repair, I&D of simple abscess, etc.Discussion of Discharge Instructions (Simple) | Localized skin rash, lesion, sunburnMinor viral infectionEye discharge- painlessEar PainUrinary frequency without feverSimple trauma (with no X-rays) |
| IIICPT 99283 Type A: APC 614Type B: APC 628HCPCS: G0382 | Could include interventions from previous levels, plus any of:Receipt of EMS/Ambulance patientHeparin/saline lock(¹) Nebulizer treatmentPreparation for lab tests described in CPT (80048-87999 codes)Preparation for EKGPreparation for plain X-rays of only 1 area (hand, shoulder, pelvis, etc.)Prescription medications administered POFoley catheters; In & Out cathsC-Spine precautionsFluorescein stainEmesis/ Incontinence carePrep or assist w/procedures such as: joint aspiration/injection, simple fracture care etc.Mental Health-anxious, simple treatmentRoutine psych medical clearanceLimited social worker interventionPost mortem careDirect Admit via EDDiscussion of Discharge Instructions (Moderate Complexity) | Minor trauma (with potential complicating factors)Medical conditions requiring prescription drug managementFever which responds to antipyretics Headache – Hx of, no serial examHead injury- without neurologic symptomsEye pain Mild dyspnea -not requiring oxygen |
| IVCPT 99284 Type A: APC 615Type B: APC 629HCPCS: G0383 | Could include interventions from previous levels, plus any of:Preparation for 2 diagnostic tests²: (Labs, EKG, X-ray)Prep for plain X-ray (multiple body areas):C-spine & foot, shoulder & pelvisPrep for special imaging study (CT, MRI, Ultrasound,VQ scans)Cardiac Monitoring (²) Nebulizer treatmentsPort-a-cath venous access Administration and Monitoring of infusions or parenteral medications (IV, IM, IO, SC) NG/PEGTube Placement/Replacement Multiple reassessmentsPrep or assist w/procedures such as: eye irrigation with Morgan lens, bladder irrigation with 3-way foley, pelvic exam, etc.Sexual Assault Exam w/ out specimen collection Psychotic patient; not suicidalDiscussion of Discharge Instructions (Complex) | Blunt/ penetrating trauma- with limited diagnostic testingHeadache with nausea/ vomitingDehydration requiring treatmentVomiting requiring treatmentDyspnea requiring oxygenRespiratory illness relieved with (²) nebulizer treatmentsChest Pain–with limited diagnostic testingAbdominal Pain – with limited diagnostic testingNon-menstrual vaginal bleedingNeurologic symptoms – with limited diagnostic testing |
| VCPT 99285 Type A: APC 616Type B: APC 630 HCPCS: G0384 | Could include interventions from previous levels, plus any of:Requires frequent monitoring of multiple vital signs (ie. 02 sat, BP, cardiac rhythm, respiratory rate)Preparation for ≥ 3 diagnostic tests²: (Labs, EKG, X-ray)Prep for special imaging study (CT, MRI, Ultrasound, VQ scan) combined with multiple tests or parenteral medication or oral or IV contrast.Administration of Blood Transfusion/Blood Products Oxygen via face mask or NRB Multiple Nebulizer Treatments: (3) or more (if nebulizer is continuous, each 20 minute period is considered treatment)Moderate SedationPrep or assist with procedures such as: central line insertion, gastric lavage, LP, paracentesis,etc.Cooling or heating blanketExtended Social Worker interventionSexual Assault Exam w/ specimen collection by ED staffCoordination of hospital admission/ transfer or change in living situation or sitePhysical/Chemical Restraints;Suicide WatchCritical Care less than 30 minutes | Blunt/ penetrating trauma requiring multiple diagnostic testsSystemic multi-system medical emergency requiring multiple diagnosticsSevere infections requiring IV/IM antibioticsUncontrolled DMSevere burnsHypothermiaNew-onset altered mental statusHeadache (severe): CT and/or LPChest Pain–multiple diagnostic tests/treatmentsRespiratory illness–relieved by (3) or more nebulizer treatmentsAbdominal Pain–multiple diagnostic tests/treatmentsMajor musculoskeletal injuryAcute peripheral vascular compromise of extremitiesNeurologic symptoms – multiple diagnostic tests/treatmentsToxic ingestions Mental health problem – suicidal/ homicidal |
| Critical Care – Critical Care can be coded based upon either the provision of any of the listed possible interventions or by satisfying the Critical Care definition. A minimum of 30 minutes of care must be provided. Critical Care Involves decision-making of high complexity to assess, manipulate, and support impairments of “one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” This includes, but is not limited to, “the treatment or prevention of further deterioration of central nervous system failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, post-operative complications or overwhelming infection.” Under OPPS, the time that can be reported as Critical Care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once. | ||
| Possible Interventions | Potential Symptoms/Examples which support the Interventions | |
| CPT 99291Type A: APC 617 | Could include interventions from previous levels, plus any or all of:Multiple parenteral medications requiring constant monitoringProvision of any of the following:Major Trauma care/ multiple surgical consultantsChest tube insertionMajor burn careTreatment of active chest pain in ACSAdministration of IV vasoactive meds (see guidelines)CPRDefibrillation/ CardioversionPericardiocentesisAdministration of ACLS Drugs in cardiac arrestTherapeutic hypothermia Bi-PAP/ CPAPEndotracheal intubationCricothyrotomyVentilator managementArterial line placementControl of major hemorrhagePacemaker insertion through a Central LineDelivery of baby | Multiple Trauma; Head Injury with loss of consciousnessBurns threatening to life or limbComa of all etiologies (except hypoglycemic)Shock of all types: septic, cardiogenic, spinal, hypovolemic, anaphylacticDrug Overdose impairing vital functionsLife-threatening hyper/ hypo-thermiaThyroid Storm or Addisonian CrisisCerebral hemorrhage of any typeNew-onset paralysisNon-hemorrhagic strokes with vital function impairmentStatus epilepticusAcute Myocardial InfarctionCardiac Arrythmia requiring emergency treatmentAortic DissectionCardiac TamponadeAneurysm; thoracic or abdominal — leaking or rupturedTension PneumothoraxAcute respiratory failure, pulmonary edema, status asthmaticusPulmonary EmbolusEmbolus of fat or amniotic fluidAcute renal failureAcute hepatic failureDiabetic KetoacidosisLactic AcidosisDIC or other bleeding diatheses – hemophilia, ITP, TTP, leukemia, aplastic anemiaMajor Envenomation by poisonous reptiles |
| CPT 99292 | As above in additional 30 minute increments. Record the TOTAL critical care time. The first 30-74 minutes equal code 99291. If used, additional 30 minute increments (beyond the first 74 minutes) are coded 99292. Medicare does not pay for code 99292 because it is considered packaged into 99291; however the services should be reported as appropriate. | |
| Critical Care with Trauma Team ActivationAPC 618G0390 | In addition to 99291, designated trauma centers may report the Trauma Team Activation code G0390 when a trauma team was activated and all other trauma activation criteria are met. | |
| Copyright © 2011 American College of Emergency Physicians |
If you intend to use these guidelines, or an adaptation of them, Copyright permission can be requested here.
If you have questions please contact the ACEP Reimbursement Department at 1-800-798-1822.
Footnote 1: Hospital outpatient therapeutic services and supplies (including visits) must be furnished incident to a physician’s service and under the order of a physician or other qualified practitioner. Services provided by a nurse in response to a standing order do not satisfy this requirement. Since Diagnostic tests do not have to be performed incident to a physician service, they may be coded even if the patient were to leave without being seen by the physician.
Footnote 2: As of 2021, CPT has clarified that a test is defined as a service that has a separate CPT code. Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test. The differentiation between single or multiple unique tests is defined in accordance with the CPT code set.
