Emergency Department - Charge Process
Emergency Department - Charge ProcessThere are five components to the charge process for the Emergency Room:1.2.3.4.5.Assignment of evaluation and management levelNursing proceduresHospital technical component of physician proceduresMedical suppliesDrugs sold to PatientsAssignment of the evaluation and management level:The assignment of an ED E&M level is based on Nursing and hospital resources used for treatingthe Patient. The process is to assign a point value to each Nursing service or resource whichcannot be separately charged to the Patient, the sum of the point values are then “fitted” to ascale to determine the level.CMS has stated that it is not expecting to see the same E&M level charged for the Hospital asthe Physician.There are six E&M levels to be selected:1. Brief – exam only with possibly a med script2. Limited – Requires the assessment of a single symptom with limited testing or timespend with the Patient3. Intermediate – several different diagnostic tests, child requiring restraint4. Extended – Interventions and diagnostic testing, possible admit to hospital asobservation or inpatient5. Comprehensive – Major interventions or diagnostic testing, possible admit to hospitalas a inpatient6. Critical – Requires close attendance and major interventions or diagnostic testing for aextended period of time, admit to hospitalHospitals may also charge a “sub brief visit” for the following:1. Triage only2. Suture removal3. Wound checkPARA Healthcare Financial Services – November 2011Page 1
Emergency Department - Charge ProcessAssignment of the evaluation and management level (continued)HCPCS/CPT APC99281 - Emergency department visit for the evaluation and management of apatient, which requires these 3 key components: A problem focused history; Aproblem focused examination; and Straightforward medical decision making.Counseling and/or coordination of care with other providers or agencies areprovided consistent with the nature of the problem(s) and the patient's and/orfamily's needs. Usually, the presenting problem(s) are self limited or minor.0609 - Level 1 Type AEmergency Visits99282 - Emergency department visit for the evaluation and management of apatient, which requires these 3 key components: An expanded problem focusedhistory; An expanded problem focused examination; and Medical decisionmaking of low complexity. Counseling and/or coordination of care with otherproviders or agencies are provided consistent with the nature of the problem(s)and the patient's and/or family's needs. Usually, the presenting problem(s) areof low to moderate severity.0613 - Level 2 Type AEmergency Visits99283 - Emergency department visit for the evaluation and management of apatient, which requires these 3 key components: An expanded problem focusedhistory; An expanded problem focused examination; and Medical decisionmaking of moderate complexity. Counseling and/or coordination of care withother providers or agencies are provided consistent with the nature of theproblem(s) and the patient's and/or family's needs. Usually, the presentingproblem(s) are of moderate severity.0614 - Level 3 Type AEmergency Visits99284 - Emergency department visit for the evaluation and management of apatient, which requires these 3 key components: A detailed history; A detailedexamination; and Medical decision making of moderate complexity. Counselingand/or coordination of care with other providers or agencies are providedconsistent with the nature of the problem(s) and the patient's and/or family'sneeds. Usually, the presenting problem(s) are of high severity, and requireurgent evaluation by the physician but do not pose an immediate significantthreat to life or physiologic function.0615 - Level 4 Type AEmergency Visits hr/ 8003 Level II Extended Assessment& Management Composite99285 - Emergency department visit for the evaluation and management of apatient, which requires these 3 key components within the constraints imposedby the urgency of the patient's clinical condition and/or mental status: Acomprehensive history; A comprehensive examination; and Medical decisionmaking of high complexity. Counseling and/or coordination of care with otherproviders or agencies are provided consistent with the nature of the problem(s)and the patient's and/or family's needs. Usually, the presenting problem(s) areof high severity and pose an immediate significant threat to life or physiologicfunction.0616 - Level 5 Type AEmergency Visits hr/ 8003 Level II Extended Assessment& Management Composite99291 - Critical care, evaluation and management of the critically ill or criticallyinjured patient; first 30-74 minutes0617 - Critical Care hr/ 8003- Level II Extended Assessment& Management Composite99292 - Critical care, evaluation and management of the critically ill or criticallyinjured patient; each additional 30 minutes (List separately in addition to codefor primary service)PackagedPARA Healthcare Financial Services – November 2011Page 2
Emergency Department - Charge ProcessAssignment of the evaluation and management level (continued)Type B ED LevelsG0380 - LEVEL 1 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY DEPARTMENT;(THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1) IT IS LICENSED BY THE STATE INWHICH IT IS LOCATED UNDER APPLICABLE STATE LAW AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT;(2) IT IS HELD OUT TO THE PUBLIC (BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACETHAT PROVIDES CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING APREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY PRECEDING THECALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR 489.24 IS BEING MADE, BASED ON AREPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED DURING THAT CALENDAR YEAR, IT PROVIDES ATLEAST ONE-THIRD OF ALL OF ITS OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICALCONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)G0381 - LEVEL 2 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY DEPARTMENT;(THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1) IT IS LICENSED BY THE STATE INWHICH IT IS LOCATED UNDER APPLICABLE STATE LAW AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT;(2) IT IS HELD OUT TO THE PUBLIC (BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACETHAT PROVIDES CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING APREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY PRECEDING THECALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR 489.24 IS BEING MADE, BASED ON AREPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED DURING THAT CALENDAR YEAR, IT PROVIDES ATLEAST ONE-THIRD OF ALL OF ITS OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICALCONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)G0382 - LEVEL 3 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY DEPARTMENT;(THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1) IT IS LICENSED BY THE STATE INWHICH IT IS LOCATED UNDER APPLICABLE STATE LAW AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT;(2) IT IS HELD OUT TO THE PUBLIC (BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACETHAT PROVIDES CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING APREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY PRECEDING THECALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR 489.24 IS BEING MADE, BASED ON AREPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED DURING THAT CALENDAR YEAR, IT PROVIDES ATLEAST ONE-THIRD OF ALL OF ITS OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICALCONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)G0383 - LEVEL 4 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY DEPARTMENT;(THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1) IT IS LICENSED BY THE STATE INWHICH IT IS LOCATED UNDER APPLICABLE STATE LAW AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT;(2) IT IS HELD OUT TO THE PUBLIC (BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACETHAT PROVIDES CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING APREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY PRECEDING THECALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR 489.24 IS BEING MADE, BASED ON AREPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED DURING THAT CALENDAR YEAR, IT PROVIDES ATLEAST ONE-THIRD OF ALL OF ITS OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICALCONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)G0384 - LEVEL 5 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY DEPARTMENT;(THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1) IT IS LICENSED BY THE STATE INWHICH IT IS LOCATED UNDER APPLICABLE STATE LAW AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT;(2) IT IS HELD OUT TO THE PUBLIC (BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACETHAT PROVIDES CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING APREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY PRECEDING THECALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR 489.24 IS BEING MADE, BASED ON AREPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED DURING THAT CALENDAR YEAR, IT PROVIDES ATLEAST ONE-THIRD OF ALL OF ITS OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICALCONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)PARA Healthcare Financial Services – November 2011Page 3
Emergency Department - Charge ProcessAssignment of the evaluation and management level (continued):There are a number of “systems” to determine the ED level:1.2.3.4.5.6.Point assignment, accumulation of resources and “fit” to a level.T sheet documentation and levelingCharge on documentation, automated point assignment and levelingAmerican College of Emergency PhysiciansAHIMA draft on ED level assignmentChart based diagnosisPoint Assignment, accumulation of resources and “fit” to a level.PTSVALUEDESCRIPTIONCATEGORY I1 PER VISITARRANGE FOR ADMISSION3 PER VISITARRANGE TRANSFER/MOT/TRANSPORTATION1 PER 15 MIN.ASSIST W/SETUP PHYSICIAN PROCEDURE1 PER VISIT, EAASSIST RESTRAINT/MOBILITY/FEEDING/BATHING1 PER VISITDIAGNOSTICS ORDERED-CARDIOPULMONARY1 PER VISITDIAGNOSTICS ORDERED-IMAGING1 PER VISITDIAGNOSTICS ORDERED-LABORATORY1 PER VISTDISCHARGE INSTR. GIVEN & REVIEWED2 PER VISITMIGN SERVICES1 PER VISITMULTIPLE CALLS FOR ANCILLARY SERVICES1 PER 60 MIN.OBSERVATION EA MIN AFTER 1ST HRTOTAL POINTS ALL CATEGORIES:PTSASSIGN LEVEL:ASSIGN HCPCS:1TRIAGE2LEVEL 1992813-5LEVEL 2992826-8LEVEL 3992839-12LEVEL 49928413-16LEVEL 59928517 & LEVEL 699291 1ST 30-74 MINUTESPARA Healthcare Financial Services – November 2011Page 4
Emergency Department - Charge ProcessAssignment of the evaluation and management level (continued):T Sheet - Combined documentation and level assignmentAmerican College of Emergency Physicianshttp://www.acep.org/content.aspx?id 30428PARA Healthcare Financial Services – November 2011Page 5
Emergency Department - Charge ProcessAssignment of the evaluation and management level (continued):AHIMA draft on ED level ublic/documents/ahima/bok1 021426.hcsp?dDocName bok1 021426PARA Healthcare Financial Services – November 2011Page 6
Emergency Department - Charge ProcessAssignment of the evaluation and management level (continued):AHIMA draft on ED level ublic/documents/ahima/bok1 021423.pdfPARA Healthcare Financial Services – November 2011Page 7
Emergency Department - Charge ProcessAssignment of the evaluation and management level (continued):Chart based diagnosisCommunity Hospital - ED Level Assignment - Feb 2011Level 1ProceduresTriageTeaching for Patient and familyDischarge instructionsSuture removalSimple dressing changeRefill RxDiagnosisInsect / spider biteSuture removalWound re-checkOff work orderReturn to work orderMed refillRashLevel 5ProceduresAdmit toTransport with RNTransport with MonitorConscious sedation 7 pain assessmentsDiagnosisLevel 2Level 3ProceduresPO MedsPoint of care testingVisual acuityProceduresHep lockSingle diagnostic test2 pain assessmentsOxy adminComplex discharge instructionEMSSingle therapeutic processDiagnosisDiagnosisLevel 4ProceduresSlit lamp examMorgan lensCervical examMulti diagnostic testNG/Peg tube - reinsertCardiac monitor / pulse ox3 - 6 pain assessmentsMultiple therapeutic processDiagnosisEar PainUTISimple sprainConjunctivitisSimple wound evalUpper resp. infectionChronic Back painSore throatAcute back painExtensive wound evalAdult asthmaAbd painEval simple fxMigraineChronic chest painAcute BronchitisAcute panicForeign Body eyeAcute headacheDyspnea w meds5150 less than 4 hoursChild asthmaVaginal bleedingDOA post mortem careChronic coughCOPDAltered LOCFeverHeadacheHypertensionAbscess - simpleComplex fx - open / multiAdmit to ObservationLeg PainIngrown toe nail1st degree burnFluForeign Body ear / noseAllergic reactionAnimal biteDental PainAssault2nd degree burnAdmit to Med/SurgCellulitisGI BleedKidney stoneSyncopeHypertensionShort of breathAcute chest painSepsisDKAHHNT5150 greater than 4 hoursETOH / OverdoseResp. distressHypertensive CrisisAnginaComplete cardiac eval3rd degree burnPARA Healthcare Financial Services – November 2011AnginaAssault with reportPage 8
Emergency Department - Charge ProcessAssignment of the evaluation and management level (continued):Critical care Patients may not require the assignment of points due to their extreme resourceconsumption; several of the “life saving interventions” a critical care Patient may have (basedon the Emergency Severity Index, Version 4) are as follows:1. BVM ventilation2. Intubation3. Surgical airway4. Emergent BIPAP/CPAP5. Defibrillation6. Emergent cardio version7. External pacing8. Chest needle decompression9. Pericardiocentesis10. Open thoracotomy11. Intraosseous access12. Significant IV fluid resuscitation13. Blood administration14. Control of major of bleeding15. Admin of medications – Naloxone, D50, Dopamine, Adenocardhttp://www.ahrq.gov/research/esi/PARA Healthcare Financial Services – November 2011Page 9
Emergency Department - Charge ProcessAssignment of the evaluation and management level (continued):Patients admitted as observation or inpatients must meet InterQual or a similar casemanagement standard to be sure the admission is approved for reimbursement.http://www.mckesson.com/en Support.htmlPatients held an extended period of time to be prepped for surgery, stabilization or admissionwill be assigned additional points or resources for level assignment.It is usually the case that a pregnant woman will be triaged at the ED and then “referred” to theobstetric department for an OB medical screen. This sometimes results in duplicate evaluationand management charges, ED and OB. It is suggested that the “discharging” department be thedepartment to charge the E&M visit charge.PARA Healthcare Financial Services – November 2011Page 10
Emergency Department - Charge ProcessAssignment of the evaluation and management level (continued):As presented there are a number of methods to determine the E&M levels. Within the annualrelease of the OPPS Rule, there is a yearly recommendation that a hospital establish a processto assign the levels and that the process be documented for replication. There is also anexpectation that the distribution of the E&M levels (99281 – 99285) by frequency of visitsfollow a normal distribution (ie bell shape curve).http://en.wikipedia.org/wiki/Normal distributionPARA Healthcare Financial Services – November 2011Page 11
Emergency Department - Charge ProcessNursing Procedures:There are many separately billable Nursing procedures which create line item reimbursement:1. IV therapy2. Hydration therapy3. Injections sq/im and injection into IV lines4. Catheter insertions5. Vaccine injections6. Strapping and casting (if no reduction or relocation)7. PICC line inserts8. Point of care lab tests9. Blood draw from a fully implanted port10. Blood draw from a central or PICC line11. Declotting by thrombolytic agent of a “implanted” vascular access deviceThe billable Nursing procedures are listed on the charge form and multiple services can bechecked for additional and subsequent procedures.Services which are not separately billable (to be considered part of the point / resourceassignment ED level):1.2.3.4.5.6.7.IV startsInstall Hep line / Saline lockFecal impactionEar wax removalSteri-strip applicationCleaning of wounds without a closureHep / saline lock flushPARA Healthcare Financial Services – November 2011Page 12
Emergency Department - Charge ProcessNursing Procedures:There are many rules on the admin of IV hydration, IV med therapy, and injections into an IVline. The basic rule is that only a single “initial or 1st” infusion or injection can be charged.1.2.3.4.5.6.7.96365 – IV med therapy - 1st hour96366 - IV med therapy - each additional hour96374 – IV med injection – 1st med96375 – IV med injection – 2nd med subsequent injection96376 – IV med injection – 1st med subsequent injection96360 – IV hydration – 1st hour96361 – IV hydration – each additional hourA hydration must be supported by a diagnosis; a 1st hour IV med therapy must last a minimumof 15 minutes, otherwise it is to be considered an IV injection.PARA Healthcare Financial Services – November 2011Page 13
Emergency Department - Charge ProcessHospital technical component of Physician procedures:Physicians assign the E&M level based on the “complexity of the medical decision process” andthe Hospital E&M is based on Patient resource consumption, therefore it will occur that thePhysician and Hospital E&M level assignment may differ.Because the Physician performs procedures in the Hospital ED setting, the Physician is requiredto bill with a “site of service” indicator on the 1500 form as “hospital emergency department”,this “site of service” reduces the reimbursement to the Physician and allows the Hospital to billa technical component for all Physician performed procedures.The example pasted below shows the difference between facility (hospital based) and nonfacility reimbursement.Place of service code link, pasted /CMS%20Place%20of%20Service%202011.pdfPARA Healthcare Financial Services – November 2011Page 14
Emergency Department - Charge ProcessHospital technical component of Physician procedures:ED Physicians must perform the follow-up care associated with surgical procedures subject tothe global follow-up period.If a Patient is to be “directed” to a Physician other than the Physician who performed the initialservice, the charge must have a modifier “54” “Surgical Care Only”.The Physician who then performs the follow-up care must bill with a modifier “55”“Postoperative Care Only”, both of the modifiers result in reduced reimbursement to thePhysician.The example pasted below, provides a comparison of the global day follow-up period.All Physician procedures should be checked on the hospital charge form to generate the correctreimbursement for the hospital.A physician cannot charge for a procedure which was not personally performed by thephysician (ie IV infusions, injections, and hydrations).If the Physician ED interventions are not specifically indentified and coded on the hospitalcharge sheet, some hospitals will use a system to classify the intervention into one of threelevels based on the direct time the ED Nurse spends with the Patient assisting the Physician:1. Simple – less than 15 minutes2. Intermediate – 15 to 30 minutes3. Extensive – greater than 30 minut
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