Background

Emergency Department (ED) visits should be coded based on hospital resource utilization which is dictated by the patient’s clinical condition and the treatment provided. There are five visit levels that the ED can choose from when submitting claims. Visit level 1 is the least resource-intensive for the facility and visit level 5 is the most resource-intensive. These visit levels are represented by the following Evaluation and Management (E&M) procedure codes:

Procedure Codes and Corresponding Levels for ED Claims

Visit Level Procedure Codes* Explanation
199281/G0380Used for very simple and limited services. The presenting problem is usually self-limited or minor.
299282/G0381Typically assigned for an acute episodic illness and/or minor injury evaluation. The presenting problem is of low to moderate severity.
399283/G0382Generally requires additional facility resources including x-ray, laboratory testing or additional nursing time. The presenting problem is of moderate severity.
499284/G0383For encounters associated with acute illness or injury that requires prolonged evaluation and typically diagnostic studies, repeat nursing evaluations, or other therapeutic interventions. The presenting problem is high severity requiring urgent evaluation.
599285/G0384For encounters that are associated with serious presenting symptoms, often a life-threatening disease or injury, requiring treatment that is complex and/or resource intensive. The presenting problem is of high severity and/or poses an immediate significant threat to life or physiological function.

*Procedure codes starting with “9” above, are considered Type A codes and procedure codes starting with a “G” above are considered Type B codes. “[CMS] considers the main distinguishing feature between Type A and Type B emergency departments to be the full-time versus part-time availability of staffed areas for emergency medical care, not the process of care or the site of care (on the hospital’s main campus or offsite),” per the CY 2008 OPPS Final Rule (referenced below).

At the time of the introduction of the Medicare Outpatient Prospective Payment System (OPPS) and the associated ED Ambulatory Payment Classifications (APCs), Medicare did not specify a standard approach for classification of the acuity levels for ED E&M visit codes. Instead, facilities were instructed to use any methodology as long as it met certain Centers for Medicare and Medicaid Services (CMS) guidelines. Per the current CMS guidelines (CY 2008 OPPS Final Rule (Medicare and Medicaid Programs; Interim and Final Rule) published in the Federal Register on November 27th, 2007) the facility must bill the visit level that most reasonably relates to the intensity of hospital resources used in the treatment of the patient.

CMS Guidelines

CMS Guidelines
1Follow the intent of the CPT® code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code
2Be based on hospital facility resources, not on physician resources
3Be clear to facilitate accurate payments and be usable for compliance purposes and audits
4Meet the HIPPA requirements
5Only require documentation that is clinically necessary for patient care
6Not facilitate upcoding or gaming
7Be written or recorded, well documented and provide the basis of selection of a specific code
8Be applied consistently across patients in the clinic or emergency department to which they apply
9Not change with great frequency
10 Be readily available for fiscal intermediary (or if applicable, MAC contractor) review
11 Result in coding decisions that could be verified by other hospital staff, as well as outside sources

Increasingly, facilities are submitting ED claims with higher visit levels (visit levels 4 and 5). Without access to each patient’s medical record, it is difficult for Payers to systematically determine if the visit level submitted on each claim is appropriate. Inappropriate coding can lead to improper reimbursement. The EDC Analyzer™ assists Payers with this problem by evaluating each ED visit code, in the context of other claim data (i.e., diagnosis codes, procedure codes, patient age, and patient gender), to determine if it reasonably relates to the intensity of hospital resources.

The methodology used by the EDC Analyzer™ was derived from the Optum Lynx Charge Capture (OCC) tool. Optum, through its Optum360 division, offers EDs its OCC tool for categorizing ED facility E&M visit codes. This tool currently processes over 40 million ED visits a year, roughly 30% of the US market. The algorithm underlying the tool correlates closely with visit costs, length, and intensity. Over the past several years, the distribution of E&M codes for EDs using the OCC tool has remained relatively constant (less than a 1% aggregate change) and the distribution is considered conservative compared to the main competitive methodology.