How ER Facility coding guidelines are determined?
"Outpatient Prospective Payment System" (OPPS) for hospital outpatient services; analogous to the Medicare prospective payment system for hospital inpatients known as "Diagnosis Related Groups" or DRG's. APC's or "Ambulatory Payment Classifications" are the government's method of paying for facility outpatient services for the Medicare program. APC's apply only to hospitals, and have no impact on physician payments under the Medicare Physician Fee Schedule.
Facility coding guidelines are inherently different from professional coding guidelines. Facility coding reflects the volume and intensity of resources utilized by the facility to provide patient care, whereas professional codes are determined based on the complexity and intensity of provider performed work and include the cognitive effort expended by the provider.
As such, there is no definitive strong correlation between facility and professional coding and thus no rational basis for the application of one set of derived codes, either facility or professional, to the determination of the other on a case-by-case basis.
A hospital may bill a visit code based on the hospital's own coding guidelines which must reasonably relate the intensity of hospital resources to different levels of HCPCS codes. Services furnished must be medically necessary and documented. “Facility billing guidelines should be designed to reasonably relate the intensity of hospital services to the different levels of effort represented by the codes.”
Coding guidelines should be based on facility resources, should be clear to facilitate accurate payments, should only require documentation that is clinically necessary for patient care, and should not facilitate upcoding or gaming.
When will you code Observation in Emergency department?
Observation is defined by the service provided, not the area of the hospital a patient is located in, that is, the patient does not have to be admitted to an observation unit in order for the emergency room physician to provide observation care.
Emergency physicians can use observation codes whenever there is diagnostic uncertainty requiring extended evaluations, treatments and serial examinations to determine whether a patient requires admission or can be safely discharged home.
These codes are used for Medicare patients who spend <8 hours in observation status.
Observation care codes are not separately reimbursable services when performed within the assigned global period as these codes are included in the global package.
Coding for Procedures done at ER Facility
Skin Repair
Simple – superficial single layer suture or Staple (or Dermabond) Intermediate – layered closure or single layer with debridement or removal of foreign body. Extensive cleaning, debridement or removal of particulate matter with a 1-layer closure qualifies as and intermediate repair. Complex – multi-layers or revisions.
Fracture Care Services
Physician in ED must provide the definitive care such as “manipulation,” “stabilization,” “fixation,” or “restorative care.” Initial treatment and stabilization of a fracture is considered the “significant portion” of care under CMS rules.
Splints and Strapping
A device that provides emergency immobilization for any injury suspected of fracture, dislocation or subluxation
• Static Splints – keep an injury immobilized
• Dynamic Splints – allow for movement (splints that have a joint or are hinged)
IV Hierarchy
- Chemo infusions (96413-96417, 96420-96425)
- Chemo injections (96401-96409)
- Non-chemo, therapeutic infusions (96365-96368)
- Non-chemo, therapeutic injections (96372-96377)
- Hydration infusions (96360, 96361)
Facility coding demands high standards from the coding staff certification, years of experience in the patient types they code, annual education on coding updates and
emphasis on CMS coding standards.
Our ED facility coders are skilled in identifying and assigning appropriate CPT codes for all ED physician and nurse procedures.
We have deep depth knowledge of coding the E/M levels (99281-99285), critical care codes (99291-99292), IV infusions, the medications supplies and other procedures frequently done in ED facility
Our trained medical coding professionals Can better handle issues such as medical necessity, claim denials, bundling issues and charge capture.
We offer 15 days free trial period for all Coding Services.
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