Facility coding in the Emergency Department (ED) operates under a distinct set of principles compared to professional coding. For healthcare facilities, particularly in the ED setting, accurate coding is crucial for appropriate reimbursement and compliance. This guide delves into the intricacies of ED facility coding, with a specific focus on critical care services, drawing insights from established guidelines and best practices. Understanding these guidelines is essential for hospitals and coding professionals to ensure accurate billing and reflect the intensity of resources utilized in patient care.
Understanding Outpatient Prospective Payment System (OPPS) and Ambulatory Payment Classifications (APCs)
The foundation of facility coding for outpatient services, including those in the ED, is the Medicare Outpatient Prospective Payment System (OPPS). Established as part of the Federal Balanced Budget Act of 1997, OPPS, managed by the Centers for Medicare & Medicaid Services (CMS), utilizes Ambulatory Payment Classifications (APCs). APCs are the standardized method Medicare employs to reimburse hospitals for outpatient facility services. It is important to note that APCs exclusively apply to hospitals and do not influence physician payments, which are governed by the Medicare Physician Fee Schedule.
Facility coding is inherently resource-based, reflecting the volume and intensity of resources a hospital expends to deliver patient care. This contrasts with professional coding, which is based on the complexity of the physician’s work, including their cognitive effort. Due to these fundamental differences, there isn’t a direct, one-to-one correlation between facility and professional coding. Applying one set of codes to determine the other is not a valid approach in healthcare billing.
CMS Guidelines on Facility Coding and “Triage-Only” Visits
CMS provides specific guidance on facility coding, emphasizing the hospital’s responsibility in establishing its own coding guidelines. In the 2011 OPPS guidelines, CMS clarified its stance on “triage-only” visits, affirming that hospitals have the autonomy to define their coding based on their internal guidelines. These guidelines must reasonably link the intensity of hospital resources to different Healthcare Common Procedure Coding System (HCPCS) codes. Crucially, all services billed must be medically necessary and thoroughly documented.
However, a 2012 CMS Facility FAQ introduced an important distinction. Hospital outpatient therapeutic services and supplies, including visits, must be “incident to” a physician’s service and ordered by a physician or qualified practitioner. Services performed by nurses under standing orders alone do not meet this “incident to” requirement. Conversely, diagnostic services are exempt from this requirement. They can be coded even if a patient leaves before being examined by a physician, as diagnostic services are inherently ordered and interpreted by a physician, even if not directly face-to-face.
Currently, there is no national standardized system mandated by CMS for assigning Evaluation and Management (E&M) code levels for outpatient services in hospital clinics and Emergency Departments. CMS mandates that each hospital must create its own facility billing guidelines. These guidelines are expected to adhere to eleven criteria outlined by OPPS, ensuring they accurately reflect the intensity of hospital services for different code levels. Effective facility billing guidelines should be:
- Resource-based, reflecting the resources utilized by the facility.
- Clear and unambiguous to facilitate accurate payments.
- Based only on documentation that is clinically necessary for patient care.
- Designed to prevent upcoding or gaming of the system.
Hospitals should consult the 2009 CMS Final Rule for detailed information on facility billing and the OPPS rule summary available on resources like the American College of Emergency Physicians (ACEP) website.
ACEP Facility Coding Guidelines: A Model for Emergency Departments
Recognizing the need for practical guidance, ACEP has developed facility billing guidelines that align with OPPS principles. These guidelines offer a potential framework for hospitals, particularly EDs, to adopt or adapt to their specific institutional needs. ACEP’s model aims to provide an easy-to-use methodology for assigning visit levels in the ED, ensuring appropriate coding based on the intensity of facility resources.
Instructions for Utilizing ACEP Facility Coding Guidelines
The ACEP facility coding model is structured in a user-friendly table format with three columns:
- Facility Codes and APC Levels: Located in the far-left column, this section lists the facility codes (CPT codes 99281-99285 and 99291 for critical care) and their corresponding APC levels.
- Possible Interventions: The middle column details the “Possible Interventions” performed by nursing and ancillary staff in the ED. These interventions are the primary determinant of the appropriate facility code level. It is important to note that these interventions refer to facility staff actions, not physician interventions. This column also includes examples of procedures that might be billed separately by the facility, acting as proxies for the intensity of facility services.
- Potential Symptoms/Examples: The far-right column provides “Potential Symptoms/Examples” that may support the interventions listed in the middle column. This column serves as an aid for coders to correlate symptoms with intervention levels but is not used to determine the facility code level.
The appropriate facility code/APC level is solely determined by the “Possible Interventions” performed by nursing and ancillary ED staff, as listed in the middle column. If an intervention is listed under a specific facility code level, and no interventions from higher levels are performed, then that facility code level is assigned. Multiple interventions within the same facility code level do not change the assigned level; it remains the highest level for which at least one “Possible Intervention” is documented.
The phrase “Could include interventions from previous (lower) levels, plus any of:” in the “Possible Interventions” column indicates a cumulative effect. For instance, if the highest level intervention is at the 99283 level, the facility code is 99283, regardless of whether interventions from levels 99281 or 99282 were also performed. The assigned facility code level is always the highest level where at least one “Possible Intervention” is documented.
Examples of Facility Coding Application
Example #1: Complex Pelvic Pain Case
Consider a 48-year-old woman with a history of myocardial infarction and atrial fibrillation presenting to the ED with pelvic pain. ED staff interventions include:
- Initial nursing assessment.
- Stool hemoccult and urine dipstick tests.
- Saline lock insertion and blood draw for lab tests.
- Foley catheter insertion for urine specimen collection.
- ED nurse attendance during physician’s pelvic exam.
- Preparation and transport to radiology for pelvic ultrasound with cardiac monitoring during transport.
- Complex discharge instructions provided by the nurse.
Using the ACEP guidelines, the coder identifies “Abdominal Pain” (similar to pelvic pain) listed at levels 99284 and 99285. Reviewing the 99285 “Possible Interventions,” the coder finds:
- Monitoring vital signs during in-hospital transport.
- Discussion of “Complex” Discharge Instructions.
Since interventions at the 99285 level are documented, the appropriate facility code is 99285 (APC 616).
Example #2: Uncomplicated Urinary Tract Infection (UTI)
A 66-year-old woman with no significant medical history presents to the ED with low-grade fever, dysuria, and urinary frequency. ED staff interventions include:
- Nursing assessment.
- Urine dipstick test.
- “In and out” Foley catheterization for urine specimen.
- Administration of Pyridium and Sulfamethoxazole/Trimethoprim PO in the ED.
- Moderate complexity discharge instructions.
The coder identifies “Medical conditions requiring prescription drug management” and “Fever which responds to antipyretics” in the “Potential Symptoms/Examples” column, aligning with level 99283. Reviewing 99283 “Possible Interventions,” the coder finds:
- Prescription medications administered PO.
- Foley catheters; In & Out caths.
- Discussion of discharge instructions (Moderate Complexity).
As the highest level intervention is at 99283, the appropriate facility code is 99283 (APC 614).
Critical Care Facility Coding (CPT 99291 – APC Level 617)
Coding for critical care facility services (CPT 99291) follows the same principles as the E&M codes 99281-99285. A key requirement for critical care coding is a minimum of 30 minutes of critical care time provided.
A significant indicator of critical care is the administration and monitoring of IV vasoactive medications such as adenosine, dopamine, labetolol, metoprolol, nitroglycerin, norepinephrine, and sodium nitroprusside. These medications are typically used in unstable patients requiring intensive monitoring and intervention.
Example: Status Epilepticus Case
Consider a 68-year-old man brought to the ED by EMS in status epilepticus. ED interventions include:
- Multiple diagnostic tests.
- 2 mg Ativan IV followed by IV Dilantin infusion over one hour.
- IV sodium nitroprusside infusion to manage hypertensive crisis (BP 240/140 reduced to 180/110).
- CT scan revealing intracerebral hemorrhage.
- Transfer to another hospital for neurosurgical care.
- Documented 45 minutes of critical care time.
Using the ACEP guidelines, the coder finds “Status-Asthmaticus, Epilepticus” and “Cerebral Hemorrhage of any type” listed under the “Critical Care” section in the “Potential Symptoms/Examples” column. Furthermore, the intervention of “Multiple parenteral medications requiring constant monitoring” is found under “Critical Care” “Possible Interventions,” evidenced by the IV drips of Dilantin and sodium nitroprusside.
With 45 minutes of documented critical care time and at least one “Possible Intervention” from the critical care level, the appropriate facility code is 99291 (APC 617).
Definitions of Discharge Instructions Complexity
The ACEP guidelines also define levels of discharge instruction complexity, which factor into the E&M coding levels:
- Straightforward: For self-limited conditions requiring no medications or home treatment, only explanation of wound infection signs/symptoms and instructions to return to ED if problems arise.
- Simple: Involving over-the-counter (OTC) medications or simple treatments like dressing changes; patient quickly and easily demonstrates understanding.
- Moderate: Including head injury instructions, crutch training, lifting/weight-bearing limitations, prescription medications with side effect review; patient may have questions but generally understands instructions verbally or by demonstration.
- Complex: Involving multiple prescription medications and/or home therapies with side effect review, diabetes, seizure, or asthma teaching for compromised/non-compliant patients; patient/caregiver may struggle to understand and require additional support for compliance.
Disclaimer and Further Information
It is crucial to remember that the ACEP ED Facility Level Coding Guidelines are for informational purposes only and represent the editorial opinion of ACEP. While developed from knowledgeable sources, ACEP does not guarantee the accuracy or completeness of the guidelines and disclaims liability for damages arising from their use. These guidelines should not be considered the definitive reference for CMS OPPS coding. OPPS coding is case-specific and subject to change with evolving practices. Payment policies are determined by CMS, and specific payment-related questions should be directed to CMS.
For questions regarding these guidelines, contact the ACEP Reimbursement Department at 1-800-798-1822. For copyright permission to use or adapt these guidelines, requests can be submitted via the ACEP website.
Footnote 1: Hospital outpatient therapeutic services require physician order and “incident to” physician service. Diagnostic tests do not require “incident to” criteria.
Footnote 2: CPT defines a “test” as a service with a separate CPT code, including imaging, lab, psychometric, or physiologic data. A lab panel is considered a single test. Differentiation between single and multiple tests follows CPT code set definitions.
