For many, the ins and outs of facility evaluation and management (E/M) coding for emergency department (ED) services are shrouded in mystery.  In an industry where everything seems to be regulated, there appears to be a lack of regulation in the world of facility ED E/M.  But is there really?  I’ve been known to fib a little about facility ED E/M coding but quickly backtrack to simply state, “It’s complicated.”  So without further ado, here are three little lies I’ve told about facility E/M coding and the real truths behind them.

Lie #1: There is no ED E/M coding in the facility setting

I admit, this one is usually told to newbie coders who are freaking out about passing their certification exams because they just don’t get E/M coding.  While there is E/M coding in the facility setting, it in no way resembles its pro-fee cousin.  This mistruth is generally meant to soothe new coders who haven’t yet entered the workforce.  Being a bad E/M coder doesn’t mean your coding career is over.  Case in point: I couldn’t code a pro-fee E/M level to save my life and I’ve been very successful as a coder over the last 25 years… in the facility setting.

Lie #2: There are no ED E/M coding guidelines

I often tell people that there are no rules for facility ED E/M coding other than CMS telling us that 1) facilities should create their own rules and 2) facilities must follow them. This is an oversimplification.  There are eleven principles from CMS regarding developing internal E/M guidelines.  Specifically, facility E/M levels should:

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

Lie #3: As a facility coder, you will never need to worry about facility ED E/M coding

Okay, so this one is still mostly true.  Most hospital coders do not have to worry about assigning facility ED E/M codes.  E/M levels are usually hard coded, entered by trained charge posters, or built into the algorithms within an electronic medical record (EMR), which automatically calculates the ED level as  services are documented.  Even so, I think it’s important for coders to know how their facility ED levels are assigned.  In more advanced coding positions, you may be called upon to validate E/M levels according to your facility’s criteria or you may be consulted to update the facility’s E/M leveling criteria.

Don’t Get Too Comfortable

In June 2019, the Medicare Payment Advisory Commission (MedPAC) made the recommendation to Congress that national guidelines for coding hospital emergency visits be developed.  MedPAC is a nonpartisan legislative branch agency that advices Congress on issues pertaining to the Medicare program. This wouldn’t be the first time someone has taken a crack at developing nationally standardized guidelines, but so far, under 20 years of the outpatient prospective payment system (OPPS), nothing has come to fruition.  We can only stand by, wait for new guidelines, and adjust if and when the time comes.

Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer

Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer

Senior Consultant

Kristi is a senior consultant with more than 20 years of industry experience; she is responsible for the development of web-based, instructor-led, and webinar training materials; conducting training in ICD-10-CM/PCS and CPT; and performing DRG and APC audits. Kristi has an extensive background in coding education and consulting and is a national speaker on topics related to ICD-10 and CPT coding as well as code-based reimbursement. She has designed and developed training programs for inpatient and outpatient hospital-based coding, including vascular interventional radiology, interventional cardiology, orthopedics, and obstetrics.

Kristi has served the Colorado Health Information Management Association (CHIMA) as board Director, co-chair of the Data Quality Committee, and co-chair for the ICD-10 Task Force. She is also a past president of the Northern Colorado Health Information Management Association (NCHIMA). Kristi devotes extra time to mentoring current and future coders through her Coder Coach blog and is the proud recipient of the 2011 AHIMA Triumph Award for Mentoring. She has also received awards from CHIMA for Distinguished Member (2018) and Outstanding Volunteer (2013) and from AHIMA for Roundtable Achievement in Coding Excellence (RACE).


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