Hospitals and physician practices are increasingly affected by overwhelming number of payer denials without basis. Initially these denials affected primarily physician billing but of late, they have expanded to the facility portion of the ED charge and present growing challenges for hospitals struggling to staff their RCM departments to handle the constantly increasing numbers. When attempting to manage denials, a general “roadmap” can be effective to address the details supporting provider selection of charge codes. A review of the best content elements can assist in providing payers with undeniable support for the services rendered.

Content of Facility Coding Criteria

The Federal Register (Vol. 68, No. 155, p. 63461 -48008 -48010) outlined the Medicare conditions for charging the Facility component of an ED visit as follows, “Facilities code clinic and emergency department visits using the same (Physicians) Current Procedural Terminology codes as physicians. For both clinic and emergency department visits, there are currently five levels of care (99281-99285) plus Critical Care (99291-99292). Because these codes are defined to reflect only the activities of physicians, they are inadequate to describe the range and mix of services provided by the hospital to patients in the clinic and emergency department settings (for example, ongoing nursing care, preparation for diagnostic tests and patient education).” This would establish the need for separate identification of ED Facility leveling separate and distinct from professional E/M leveling.

In the April 7, 2000 final rule (65 FR 18434), CMS gave each facility the responsibility to create an internal set of guidelines to determine the visit (E/M) level for each patient. CMS stated that hospitals should develop criteria for outpatient visits that meet the following criteria announced in the August 9, 2002 proposed rule (67 FR 52131):

• Coding guidelines for emergency and clinic visits should be based on emergency department or clinic facility resource use, rather than physician resource use.
• Coding guidelines should be clear, facilitate accurate payment, be usable for compliance purposes and audits, and comply with HIPAA.
• Coding guidelines should only require documentation that is clinically necessary for patient care.  Preferably, coding guidelines should be based on current hospital documentation requirements.
• Coding guidelines should not create incentives for inappropriate coding.

The American College of Emergency Physicians (ACEP) developed an emergency department facility coding criteria that is currently in use at a majority of U.S. Hospitals and has become the model of ED facility code assignment. However, payers often utilize proprietary facility coding criteria to approve or deny ED claims without sharing that information with their participating providers which make it increasing difficult to identify why, specifically, payment for claims is downcoded or denied.

Medical Necessity

It is not uncommon to see claims downcoded for lack of medical necessity which is a subjective concept that can be utilized by payers to downcode or deny payment for submitted claims. The American Academy of Professional Coders (AAPC) notes that CMS allows its Medicare Administrative Contractors (MACs) to determine whether services provided to their beneficiaries are reasonable and necessary, and therefore medically necessary. MACs use the following criteria to determine if an item or service is medically necessary:

• It is safe and effective.
• It is not experimental or investigational.
• It is appropriate when:

  • Furnished in accordance with accepted standards of medical practice.
  • Furnished in a setting appropriate to the medical needs and condition.
  • Ordered and furnished by qualified personnel.
  • Meets the medical need of the patient.

Note: There are some exceptions to the general medical necessity requirements spelled out in CMS’ regulations.

EMTALA (Emergency Medicine Treatment and Labor Act)

First it is necessary to recognize the standards outlined by EMTALA. According to CMS, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) in 1986 “to ensure public access to emergency services regardless of a patient’s ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.”

“Emergency medical services” means the delivery of health care services under emergency conditions occurring as the result of a patient’s condition due to a work injury that manifests itself by symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to be life-threatening or cause serious harm or aggravation of physiological or psychological sickness, injury, or incapacitation.”

According to CMS, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) in 1986 “to ensure public access to emergency services regardless of ability to pay’. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.”

Medical Screening Examination and Emergency Medical Conditions

EMTALA obligates Medicare participating hospitals to provide a medical screening examination when a patient presents to the emergency department for examination or treatment of an emergency medical condition (EMC). Until the medical screening examination is provided, hospitals may not query the patient about insurance or payment, formerly referred to as a “wallet biopsy”. Unfortunately, EMTALA is an unfunded federal mandate with the greatest responsibility placed on the hospitals and emergency physicians who provide this care shouldering the financial burden of providing EMTALA related medical care regardless of whether payment is made, according to the EMTALA Fact Sheet prepared by the American College of Emergency Physicians.

Presenting Problem vs. Final Diagnosis in Emergency Conditions

Many insurance plans are currently retrospectively denying claims for emergency departments visits by basing the determination of an emergency on a patient’s final diagnosis/medical necessity, rather than the presenting problems/symptoms. This is in direct conflict with EMTALA which requires at least a medical screening exam, including diagnostic studies until a medical emergency has been ruled out.

Outlining Components of Emergency Department Treatment Denial Reconsideration

• Summarize the reason for the reconsideration request by outlining how the originally billed code met details of code requirements, what conditions and/or treatment(s) were primary and why.
• Restate the patient demographic information and reason for visit
• Restate major patient past medical history that may be creating problems now
• Discuss the physician’ major findings from physical examination
• Detail the differential diagnosis and establish how it effects the ordering of diagnostic studies and medications
• Provide a brief description of the course of treatment in the ED and focus on any problems, modifications to medications and patient response to treatment
• Discuss how treatment meets the standards of practice for the problems being addressed. The specialty of emergency medicine has many textbooks and articles that address standards of practice and the importance can never be stressed enough.
• Summarize any findings and discussions with other providers and note their impressions and specialty of consultant
• Discuss any documented nurses notes, cautions, concerns, patient responses to treatment of any kind, changes in therapy and family concerns
• Provide discussion of Discharge orders, location, concerns for future patient care and family concerns and limitations on care provision if pertinent.
• If pertinent, discuss Chief Complaint and presenting problems vs. final diagnosis and decisions for discharge, transfer, admission and/or observation stay
• If available, compare to information on other claims that resulted in payment and stress inconsistencies in decision making by the payer