Facility coding for outpatient services, particularly in hospital settings like the Emergency Department (ED), plays a crucial role in healthcare reimbursement. Unlike professional coding, which focuses on physician services, facility coding reflects the hospital’s resource utilization in patient care. This distinction is important in understanding the nuances of coding, especially when it comes to the Moderate Level Of Care Coding. This article delves into the principles and practical application of facility coding, with a specific focus on the moderate level of care and how it’s determined in the outpatient setting.
Decoding Facility Coding: A Resource-Based Approach
The Centers for Medicare & Medicaid Services (CMS) established the Outpatient Prospective Payment System (OPPS) and Ambulatory Payment Classifications (APCs) to standardize payments for hospital outpatient services. These systems are analogous to the Diagnosis Related Groups (DRGs) used for inpatient services. It’s essential to recognize that APCs are specific to hospitals and do not affect physician payments under the Medicare Physician Fee Schedule.
Facility coding operates under different guidelines than professional coding. Facility coding is driven by the intensity of resources the hospital expends—nursing care, ancillary services, equipment, and supplies—to treat patients. In contrast, professional coding assesses the complexity of physician work, encompassing their cognitive effort, procedural skills, and patient interaction. This fundamental difference means there isn’t a direct correlation between facility and professional codes for the same patient encounter.
CMS emphasizes that hospitals should develop their own facility coding guidelines that “reasonably relate the intensity of hospital resources to different levels of HCPCS codes.” These guidelines must be transparent, facilitate accurate payments, be based on clinically necessary documentation, and prevent upcoding or gaming the system.
Navigating CMS Guidelines for Outpatient Service Coding
While there isn’t a national standard for assigning Evaluation and Management (E&M) code levels in outpatient settings like clinics and EDs, CMS provides crucial guidance. Hospitals must establish their own billing guidelines adhering to OPPS principles. These guidelines are expected to link the intensity of hospital services to the different levels of effort represented by the coding system.
CMS has clarified key aspects of outpatient service coding, including “triage-only” visits and the requirements for therapeutic and diagnostic services. For “triage-only” visits, hospitals can bill a visit code based on their internal guidelines, provided these guidelines logically connect resource intensity to HCPCS codes. Medical necessity and proper documentation are always paramount.
A critical distinction exists between therapeutic and diagnostic services. Hospital outpatient therapeutic services and supplies (including visits) must be “incident to” a physician’s service, meaning they are furnished under a physician’s order and supervision. Services provided solely based on standing orders, without direct physician involvement, do not meet this “incident to” requirement. However, diagnostic services are exempt from the “incident to” rule and can be coded even if the patient leaves before physician examination.
ACEP Facility Coding Model: A Practical Guideline
The American College of Emergency Physicians (ACEP) has developed a facility coding model that aligns with OPPS principles. This model serves as a practical tool for assigning visit levels in the ED, particularly helpful in understanding and applying moderate level of care coding.
The ACEP model uses a three-column table to guide coders:
- Facility Codes and APC Levels: Lists the CPT codes (99281-99285, 99291) and corresponding APC levels.
- Possible Interventions: Details the nursing and ancillary staff interventions justifying each code level. This is the sole determinant of the appropriate facility code.
- Potential Symptoms/Examples: Provides examples of patient symptoms that typically correlate with the interventions at each level. This column is an aid, not a determinant of the code.
The core principle of the ACEP model is to assign the facility code level based on the highest level of “Possible Intervention” performed by nursing and ancillary staff. If an intervention is listed under a specific code level, and no interventions from higher levels are performed, then that code level is assigned. Multiple interventions within the same code level do not escalate the coding level.
Instructions for Using the ACEP Coding Model
To effectively utilize the ACEP model, focus on the “Possible Interventions” column. These interventions represent the resource intensity provided by the facility. The “Potential Symptoms/Examples” column is for reference only and should not dictate the coding level.
When assessing a patient encounter, identify all “Possible Interventions” performed by nursing and ancillary staff. Locate these interventions within the ACEP table. The highest facility code level associated with any of these interventions is the appropriate code to assign.
For example, interventions listed under the 99283 code level, representing a moderate level of care, include:
- Receipt of EMS/Ambulance patient
- Heparin/saline lock
- Nebulizer treatment
- Preparation for basic lab tests, EKG, or single-area X-rays
- Oral prescription medication administration
- Foley catheter insertion
- Moderate complexity discharge instructions
If a patient’s care involves one or more of these interventions, and no interventions from the 99284 or 99285 levels are performed, then the moderate level of care code 99283 is appropriate.
Examples of Facility Coding Application
Let’s revisit the examples provided in the original guidelines to illustrate the application of the ACEP model and highlight moderate level of care coding.
Example #1: Complex Care (Facility Code 99285)
A patient with pelvic pain receives various interventions: nursing assessment, stool hemoccult and urine dipstick tests, saline lock insertion, blood draw, Foley catheter insertion, pelvic exam preparation, pelvic ultrasound preparation and transport with cardiac monitoring, and complex discharge instructions.
By reviewing the “Possible Interventions” column, we find:
- Monitoring vital signs during in-hospital transport and testing (Level 99285)
- Discussion of Discharge Instructions “Complex” (Level 99284 and 99285)
Since interventions at the 99285 level are present, the appropriate facility code is 99285 (highest level of care).
Example #2: Moderate Level of Care (Facility Code 99283)
A patient with fever and urinary symptoms receives: nursing assessment, urine dipstick via Foley catheter, oral prescription medication administration, and moderate complexity discharge instructions.
Relevant “Possible Interventions” include:
- Prescription medications administered PO (Level 99283)
- Foley catheters; In & Out caths (Level 99283)
- Discussion of discharge instructions (Moderate Complexity) (Level 99283)
The highest level of intervention is 99283. Therefore, the appropriate facility code is 99283 (moderate level of care). This example clearly demonstrates moderate level of care coding in action, where the interventions align with the resources typically associated with this level.
Alt Text: Example of moderate complexity discharge instructions, including crutch training and prescription medication review.
Deep Dive into Moderate Level of Care Coding (CPT 99283)
The moderate level of care, represented by CPT code 99283, is a frequently utilized code in ED facility coding. It signifies a level of resource intensity beyond basic assessment and minor interventions but below the high-intensity resources of codes 99284 and 99285.
Key “Possible Interventions” that typically fall under the moderate level of care (99283) include:
- Basic Diagnostic Preparations: Preparing patients for routine lab tests (like basic metabolic panels), EKGs, and single-view X-rays indicates a need for moderate facility resources in terms of staff time, supplies, and equipment.
- Medication Administration (Oral): Administering oral prescription medications signifies a condition requiring pharmaceutical intervention and nursing time for medication preparation and patient monitoring, aligning with a moderate level of care.
- Foley Catheter Procedures: Inserting Foley catheters, whether indwelling or intermittent (“in and out”), requires trained nursing staff and sterile supplies, representing a moderate level of procedural intervention.
- Moderate Complexity Discharge Instructions: Providing discharge instructions that involve over-the-counter medications or treatments, simple dressing changes, or prescription medication reviews suggests a patient condition that requires more than straightforward instructions but isn’t as complex as managing multiple prescriptions or home therapies.
Conditions often associated with moderate level of care coding (as indicated in the “Potential Symptoms/Examples” column) include:
- Minor trauma with potential complicating factors
- Medical conditions requiring prescription drug management
- Fever responsive to antipyretics
- Headache with a history but no acute serial exams
- Mild dyspnea not requiring oxygen
It’s crucial to remember that these symptoms are examples and not definitive criteria. The coding decision should always be based on the “Possible Interventions” performed.
Alt Text: Excerpt from facility coding guidelines table showing CPT codes 99282 and 99283, highlighting interventions for moderate level of care.
Critical Care Facility Coding (CPT 99291)
Critical care coding (CPT 99291) follows the same principles as E&M coding levels 99281-99285 but requires a minimum of 30 minutes of critical care time. Critical care is defined as managing patients with “impairments of one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration.”
Interventions indicative of critical care include:
- Administration and monitoring of IV vasoactive medications
- Major trauma care
- Chest tube insertion
- CPR
- Ventilator management
Example: Critical Care Coding (CPT 99291)
A patient in status epilepticus receives multiple diagnostic tests, IV Ativan and Dilantin, and IV sodium nitroprusside for hypertension. 45 minutes of critical care are documented.
“Possible Interventions” supporting critical care coding include:
- Multiple parenteral medications requiring constant monitoring
- Treatment of active chest pain in ACS (though not explicitly chest pain in this example, the severity is comparable)
- Administration of IV vasoactive medications
With documented critical care time and qualifying interventions, CPT 99291 (critical care) is appropriately assigned.
Alt Text: Excerpt from facility coding guidelines table showing CPT code 99291 for critical care, emphasizing interventions and symptoms.
Discharge Instructions: Defining Complexity Levels
The complexity of discharge instructions is also a factor in facility coding levels. The ACEP guidelines define levels of discharge instructions:
- Straightforward: Self-limited condition, no medications, simple wound care advice.
- Simple: OTC medications, simple dressings, easy patient understanding.
- Moderate: Head injury instructions, crutch training, prescription medications with side effect review, generally good patient understanding.
- Complex: Multiple prescription medications, home therapies, diabetic or asthma teaching for compromised patients, potential patient difficulty in understanding.
The level of discharge instructions contributes to the overall resource intensity and can influence the final facility code level.
Disclaimer: Context and Institutional Adaptation
It’s crucial to remember that the ACEP guidelines are for informational purposes and serve as one possible model. Hospitals should adapt these guidelines to their specific institutional needs and ensure they accurately reflect their resource utilization. These guidelines are not a definitive CMS reference, and OPPS coding is ultimately determined by CMS based on individual case circumstances.
Conclusion: Accurate Facility Coding for Optimal Reimbursement
Accurate facility coding is vital for appropriate reimbursement and reflects the valuable resources hospitals provide in outpatient settings. Understanding the principles of resource-based coding, particularly the nuances of moderate level of care coding, and utilizing practical guidelines like the ACEP model are essential for healthcare professionals involved in facility billing and compliance. By focusing on “Possible Interventions” and correctly interpreting coding guidelines, healthcare facilities can ensure accurate and compliant coding practices, leading to fair reimbursement for the services they deliver.
