Focus on facility evaluation and management leveling

Sally Eagan(seagan@askphc.com) is Managing Consultant at Pinnacle Enterprise Risk Consulting Services in Gainesville, GA.

The New York American College of Emergency Physicians (New York ACEP) posted information in late 2017 relaying to its membership that a large commercial insurance company was expected to implement a revised policy regarding Emergency Department (ED) facility evaluation and management (E/M) coding[1] affecting reimbursement practices. The new policy was to focus on ED claims reporting Level 4 or 5. The new logic would not include reviewing medical record documentation; rather, the E/M code assigned would be validated based upon the other reported codes.

You may be asking, why the change? We’ve seen changes in E/M leveling for the facility outpatient hospital clinics in 2014. The Centers for Medicare & Medicaid Services (CMS) removed the levels in all areas of the hospital, with the exception of the ED. The reason for this change, cited by the commercial insurance companies, is their national experience with inconsistencies in coding accuracy and on the E/M coding principles.[2] The previous facility leveling for clinics is still seen in the ED. CMS has not published standards or criteria for the facility E/M levels; rather, it indicated each facility should develop their own.

So, is the change warranted? The answer is not as straightforward as you may think. Many hospitals do have E/M leveling systems that result in a code most reflective of the intensity of hospital resources expended. However, depending on how the leveling system is designed, there is a possibility of artificially skewing an E/M code to a higher level than might be warranted. An example of this could be a leveling system that assigns an E/M Level 4 to the following scenario:

A female patient presents with a chief complaint of diarrhea for the past few hours. The chief complaint or presenting problem is automatically assigned a Level 3 E/M prior to any intervention or workup. The provider, as part of the workup, orders a complete blood count (CBC) and X-ray of the abdomen. The CBC and X-ray are normal. The patient is diagnosed with gastroenteritis and instructed to drink plenty of fluids to avoid dehydration. She is given oral medications to control the diarrhea and sent home.

In the above example, the emphasis is on the presenting problem, which results in an immediate assignment of an E/M Level 3 without any intervention. The presenting problem, along with the addition of the CBC and X-ray of the abdomen, results in an E/M Level 4. But does this scenario “reasonably relate the intensity of hospital resources to the level assigned”[3] as indicated by CMS? The E/M code descriptor 99284 indicates the presenting problem(s) are of high severity and require urgent evaluation by the physician.

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