Facility coding guidelines play a crucial role in the healthcare revenue cycle, particularly when it comes to critical care services. Understanding these guidelines is essential for hospitals to ensure accurate billing and compliance. This guide delves into the intricacies of facility coding, focusing on critical care and providing insights for healthcare professionals in the United States.
The landscape of hospital outpatient service payments changed significantly with the introduction of the Medicare Outpatient Prospective Payment System (OPPS) under the Federal Balanced Budget Act of 1997. This system, managed by the Centers for Medicare & Medicaid Services (CMS), utilizes Ambulatory Payment Classifications (APCs) to determine reimbursement for facility outpatient services. It’s important to note that APCs are specific to hospitals and do not affect physician payments under the Medicare Physician Fee Schedule.
Facility coding operates on different principles than professional coding. Facility coding is designed to reflect the resources a hospital expends to provide patient care, considering the volume and intensity of services. In contrast, professional coding focuses on the complexity and intensity of the work performed by healthcare providers, including their cognitive effort. This fundamental difference means there isn’t a direct correlation between facility and professional coding outcomes for the same patient encounter. One cannot be reliably derived from the other on a case-by-case basis.
CMS has affirmed the autonomy of hospitals in establishing their facility coding guidelines. Hospitals are empowered to create their own coding guidelines that reasonably link the intensity of hospital resources to different levels of Healthcare Common Procedure Coding System (HCPCS) codes. These services must always be medically necessary and thoroughly documented. While CMS doesn’t dictate the specific staff who must provide services (even for “triage-only” visits), they emphasize that therapeutic services and supplies, including visits, must be “incident to” a physician’s service and ordered by a physician or qualified practitioner. Diagnostic services, however, do not have this “incident to” requirement.
Currently, there is no nationwide standard for assigning Evaluation and Management (E&M) code levels for outpatient services in hospital clinics and Emergency Departments (EDs). CMS mandates that each hospital develop its own facility billing guidelines. These guidelines are expected to meet eleven criteria outlined in OPPS, aiming to ensure a reasonable relationship between hospital service intensity and coding levels. Crucially, these guidelines must be resource-based, transparent, clinically driven (only requiring necessary documentation), and designed to prevent upcoding or gaming the system. CMS provides further details on these requirements in their annual OPPS Final Rules.
The American College of Emergency Physicians (ACEP) has developed a set of facility billing guidelines that align with OPPS principles. These guidelines are presented as a potential model for hospitals to consider and adapt to their specific institutional needs. It’s important for facilities to evaluate and modify these guidelines to ensure they accurately reflect their unique circumstances.
Utilizing ACEP’s Facility Coding Model
The ACEP facility coding model offers a user-friendly approach for assigning visit levels within the Emergency Department. The model is structured in a table format with three key columns.
- Facility Charge Assignment (Level): The leftmost column lists the facility codes (ICPT/HCPCS) and their corresponding APC levels. These are the codes justified by the interventions described in the middle column.
- Possible Interventions: This central column details the “Possible Interventions” performed by nursing and ancillary staff in the ED. It is solely on these interventions that the facility code/APC level determination is based. These interventions are facility-resource focused, not physician services. Examples of procedures are included as proxies for service intensity, not as separately billable items within the visit code itself.
- Potential Symptoms/Examples which Support the Interventions: The rightmost column serves as a guide for coders, listing “Potential Symptoms/Examples” that are commonly associated with the interventions in the middle column. This column is for reference only and should not be used to determine the facility code/APC level.
The correct facility code/APC level is determined by identifying the highest level of “Possible Intervention” performed by nursing and ancillary ED staff. If an intervention is listed under a specific facility code level, and no interventions at higher levels were performed, then that facility code level is assigned. The presence of multiple interventions within the same facility code level does not change the assigned level; it remains the highest level at which at least one “Possible Intervention” occurred. The phrase “Could include interventions from previous (lower) levels, plus any of:” in the “Possible Interventions” column indicates a cumulative effect. For example, if the highest level intervention is at the 99283 level, the 99283 code is assigned, even if interventions from lower levels (99281, 99282) also occurred.
Example Scenario 1
Consider a 48-year-old woman with a history of myocardial infarction and atrial fibrillation presenting to the ED with pelvic pain. ED staff performs an initial nursing assessment, stool hemoccult test, and urine dipstick test. A saline lock is inserted, blood is drawn for lab tests, and a Foley catheter is placed to obtain a urine specimen. The ED physician performs a pelvic exam with a nurse in attendance. The patient is transported by ED staff (with cardiac monitoring) to radiology for a pelvic ultrasound. Following test results, the physician diagnoses a ruptured ovarian cyst, prescribes analgesics, and provides discharge instructions for OB-GYN follow-up and rest. The nurse provides “Complex” discharge instructions.
To code this encounter, the coder identifies relevant symptoms (“Pelvic Pain” or “Abdominal Pain”) and reviews the “Possible Interventions” at the 99285 level. They find two matching interventions:
- Monitoring vital signs during in-hospital transport and testing.
- Discussion of Discharge Instructions “Complex”.
Thus, the appropriate facility code is 99285 (APC 616).
Example Scenario 2
A 66-year-old woman in excellent health presents to the ED with 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 (physician ordered). The physician’s exam reveals a fever of 101°F and 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 identifies “Medical conditions requiring prescription drug management” and “Fever which responds to antipyretics” in the “Potential Symptoms/Examples” column. Reviewing “Possible Interventions” at the 99283 level, they find:
- Prescription medications administered PO.
- Foley catheters; In & Out caths.
- Discussion of discharge instructions (Moderate Complexity).
No higher-level interventions are present, so the facility code is 99283 (APC 614).
Critical Care Facility Coding (99291 – APC Level 617)
Coding for critical care services (CPT 99291) follows the same principles as E&M codes 99281-99285. A minimum of 30 minutes of critical care time is required for facility billing. Critical care is defined as involving “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 managing conditions like central nervous system failure, shock, respiratory failure, and postoperative complications. Reportable critical care time includes time spent by physicians and/or hospital staff engaged in active face-to-face critical care. Simultaneous care by multiple staff members is only counted once.
Interventions such as the administration and monitoring of IV vasoactive medications (e.g., dopamine, nitroglycerin, norepinephrine) are indicative of critical care.
Critical Care Example
A 68-year-old man is brought to the ED by EMS in status epilepticus, experiencing grand mal convulsions with brief interludes. He undergoes diagnostic tests, receives IV Ativan and a Dilantin infusion. His blood pressure is 240/140, requiring a sodium nitroprusside IV infusion to reduce it to 180/110. A CT scan reveals a small intracerebral hemorrhage. He is transferred to another hospital for neurosurgical care. 45 minutes of critical care time is documented.
The coder identifies “Status-Asthmaticus, Epilepticus” and “Cerebral Hemorrhage of any type” under “Potential Symptoms/Examples” for Critical Care. The intervention “Multiple parenteral medications requiring constant monitoring” is also documented. With 45 minutes of critical care time and at least one “Possible Intervention” at the critical care level, the coder assigns Critical Care code 99291 (APC 617).
Definitions of Discharge Instructions Complexity
- Straightforward: Self-limited condition, no medications or home treatment, wound infection signs explained, return to ED instructions.
- Simple: OTC medications/treatment, simple dressing changes, patient demonstrates understanding easily.
- Moderate: Head injury instructions, crutch training, lifting/weight-bearing limits, prescription medication review (side effects), patient has some questions but understands.
- Complex: Multiple prescription medications/home therapies (side effects review), diabetic/seizure/asthma teaching in compromised patients, patient/caregiver struggles to understand, needs extra support for compliance.
Disclaimer
The ACEP ED Facility Level Coding Guidelines are for informational purposes only and represent the editorial opinion of knowledgeable sources. ACEP does not warrant the accuracy or completeness of the guidelines and disclaims liability for damages arising from their use. These guidelines are not a definitive reference for CMS OPPS coding, which depends on individual case circumstances and evolving practices. OPPS payment policies are determined by CMS, and specific payment questions should be directed to CMS.
| Facility Charge Assignment | ||
|---|---|---|
| Level | Possible Interventions1 | Potential Symptoms/Examples which support the Interventions |
| ICPT 99281 Type A: APC 609 Type B: APC 626 HCPCS: G0380 |
Initial Assessment No medication or treatments Rx refill only, asymptomatic Note for Work or School Wound recheck Booster or follow up immunization, no acute injury Dressing changes (uncomplicated) Suture removal (uncomplicated) Discussion of Discharge Instructions (Straightforward) |
Insect bite (uncomplicated) Read Tb test |
| IICPT 99282 Type A: APC 613 Type B: APC 627 HCPCS: 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 urine Apply ace wrap or sling Prep or assist w/ procedures such as: minor laceration repair, I&D of simple abscess, etc. Discussion of Discharge Instructions (Simple) |
Localized skin rash, lesion, sunburn Minor viral infection Eye discharge- painless Ear Pain Urinary frequency without fever Simple trauma (with no X-rays) |
| IIICPT 99283 Type A: APC 614 Type B: APC 628 HCPCS: G0382 |
Could include interventions from previous levels, plus any of: Receipt of EMS/Ambulance patient Heparin/saline lock1 Nebulizer treatment Preparation for lab tests described in CPT (80048-87999 codes) Preparation for EKG Preparation for plain X-rays of only 1 area (hand, shoulder, pelvis, etc.) Prescription medications administered PO Foley catheters; In & Out caths C-Spine precautions Fluorescein stain Emesis/ Incontinence care Prep or assist w/procedures such as: joint aspiration/injection, simple fracture care etc. Mental Health-anxious, simple treatment Routine psych medical clearance Limited social worker intervention Post mortem care Direct Admit via ED Discussion of Discharge Instructions (Moderate Complexity) |
Minor trauma (with potential complicating factors) Medical conditions requiring prescription drug management Fever which responds to antipyretics Headache – Hx of, no serial exam Head injury- without neurologic symptoms Eye pain Mild dyspnea -not requiring oxygen |
| IVCPT 99284 Type A: APC 615 Type B: APC 629 HCPCS: 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 & pelvis Prep for special imaging study (CT, MRI, Ultrasound,VQ scans) Cardiac Monitoring2 Nebulizer treatments Port-a-cath venous access Administration and Monitoring of infusions or parenteral medications (IV, IM, IO, SC) NG/PEGTube Placement/Replacement Multiple reassessments Prep 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 suicidal Discussion of Discharge Instructions (Complex) |
Blunt/ penetrating trauma- with limited diagnostic testing Headache with nausea/ vomiting Dehydration requiring treatment Vomiting requiring treatment Dyspnea requiring oxygen Respiratory illness relieved with (2) nebulizer treatments Chest Pain–with limited diagnostic testing Abdominal Pain – with limited diagnostic testing Non-menstrual vaginal bleeding Neurologic symptoms – with limited diagnostic testing |
| VCPT 99285 Type A: APC 616 Type 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 Sedation Prep or assist with procedures such as: central line insertion, gastric lavage, LP, paracentesis,etc. Cooling or heating blanket Extended Social Worker intervention Sexual Assault Exam w/ specimen collection by ED staff Coordination of hospital admission/ transfer or change in living situation or site Physical/Chemical Restraints; Suicide Watch Critical Care less than 30 minutes |
Blunt/ penetrating trauma requiring multiple diagnostic tests Systemic multi-system medical emergency requiring multiple diagnostics Severe infections requiring IV/IM antibiotics Uncontrolled DM Severe burns Hypothermia New-onset altered mental status Headache (severe): CT and/or LP Chest Pain–multiple diagnostic tests/treatments Respiratory illness–relieved by (3) or more nebulizer treatments Abdominal Pain–multiple diagnostic tests/treatments Major musculoskeletal injury Acute peripheral vascular compromise of extremities Neurologic symptoms – multiple diagnostic tests/treatments Toxic 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 99291 Type A: APC 617 |
Could include interventions from previous levels, plus any or all of: Multiple parenteral medications requiring constant monitoring Provision of any of the following: Major Trauma care/ multiple surgical consultants Chest tube insertion Major burn care Treatment of active chest pain in ACS Administration of IV vasoactive meds (see guidelines) CPR Defibrillation/ Cardioversion Pericardiocentesis Administration of ACLS Drugs in cardiac arrest Therapeutic hypothermia Bi-PAP/ CPAP Endotracheal intubation Cricothyrotomy Ventilator management Arterial line placement Control of major hemorrhage Pacemaker insertion through a Central Line Delivery of baby |
Multiple Trauma; Head Injury with loss of consciousness Burns threatening to life or limb Coma of all etiologies (except hypoglycemic) Shock of all types: septic, cardiogenic, spinal, hypovolemic, anaphylactic Drug Overdose impairing vital functions Life-threatening hyper/ hypo-thermia Thyroid Storm or Addisonian Crisis Cerebral hemorrhage of any type New-onset paralysis Non-hemorrhagic strokes with vital function impairment Status epilepticus Acute Myocardial Infarction Cardiac Arrythmia requiring emergency treatment Aortic Dissection Cardiac Tamponade Aneurysm; thoracic or abdominal — leaking or ruptured Tension Pneumothorax Acute respiratory failure, pulmonary edema, status asthmaticus Pulmonary Embolus Embolus of fat or amniotic fluid Acute renal failure Acute hepatic failure Diabetic Ketoacidosis Lactic Acidosis DIC or other bleeding diatheses – hemophilia, ITP, TTP, leukemia, aplastic anemia Major 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 Activation APC 618 G0390 |
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.
