National guideline changes for ED E/M coding due by 2022

March 18, 2019 / By Barbara Aubry, RN

According to a March 7, 2019 article in Modern Healthcarethe Medicare Payment Advisory Commission (MedPAC) has decided to recommend that HHS revisit the national ED coding rules by 2022, citing “rampant coding problems under the Outpatient Prospective Payment System.” The panel will likely vote on this recommendation during its April meeting:

“There needs to be some guidance to hospitals in how to code in these situations,” said MedPAC member Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.

Commission member Brian DeBusk also supported a national guideline but with a key caveat. “I would ask the guideline at least contemplate the concept that if a beneficiary is receiving what amounts to non-emergency care in an emergency department then it be coded to an outpatient clinic,” said DeBusk, president and CEO of the healthcare product manufacturer DeRoyal Industries in Tennessee.

He said that he isn’t arguing for a site-neutral payment, just a change of the code from an emergency department visit to an outpatient visit depending on the care provided. MedPAC said that the CMS has tried before to create a national guideline when the OPPS went online in 2000 but were unsuccessful. It did not elaborate on why the agency’s scuttled the attempt.”

Now, CMS allows hospitals to develop internal guidelines to properly report an Emergency Department visit. Some hospitals follow policies created by the American Hospital Association; others use specialty society guidelines including the American College of Emergency Physicians. At the meeting, MedPAC shared a report which revealed hospitals are seeking higher payments from CMS for ED visits. Hospital coders are to assign an ED E/M level based on documentation in the ED record.

MedPAC performed an analysis of cost statistics from CMS: In 2005, 10 percent of ED visits were coded at a level five, which represents the most complicated cases. By 2017, the report noted, level five visits increased by 30 percent. The panel also looked at data from the National Hospital Ambulatory Medical Care Survey from 2011 to 2016 showing increased use in screening services such as CT scans and EKGs for ED visits but no change in lab tests and procedures.

MedPAC’s analysis could not find a clear explanation for the change in coding that has taken place in recent years.

My take

CMS has been generous in its allowance of hospital self-governance in the reporting and coding of ED services. Interestingly, if you look at the E/M codes for ED cases (99281-99288), the coding expectations pretty much mirror all outpatient coding requirements. By that I mean the recording of history, examination and medical decision making with the complexity of medical decision-making (MDM) being the tie breaker when choosing a level. The coding “rules” have not changed during the reporting period and cannot support the 30 percent increase in level five (99285) cases.

So, what’s at play here? We know relative value units are higher as levels increase. We hear reports that some use the ED as their “family doctor” which likely does not support higher acuity. With more folks insured, ED use would be expected to decline—which also does not support the increase in coding acuity. Could the increased use of radiology and cardiology testing impact the coding acuity? Perhaps, but MDM is still the essential ingredient in choosing a proper code. Also, one would expect an increase in procedures coupled with an increase in scanning and EKG findings—unless they are mostly normal and perhaps not required? What is the explanation for no increase in lab work or the performance of procedures if the patients seen are higher acuity? The use of EHR and coding systems requires a human coder to audit the results to insure proper code assignment. I wonder if that isn’t happening at some healthcare organizations? Maybe it’s increased coding outsourcing? Some facilities report issues with outsourced coding quality. If outsourcing, are coding resources credentialed and experienced?

I don’t have the answer, only a lot of questions. One thing I am sure of is that ED coding will be the newest audit target to determine the root cause of the increased coding levels, especially if a national guideline is created. But I would bet on audits beginning sooner rather than later since the OIG will likely be interested in the figures reported by MedPAC. Forewarned is forearmed as they say. Stay tuned folks…

Barbara Aubry is a regulatory analyst for 3M Health Information Systems.