"In many hospitals in the United States, a visit to the emergency room will result in a multitude of bills for the patient.  This is because today's emergency room is a symbiotic relationship made up of several businesses working towards one goal and that is to provide emergency care and services.  These businesses consist of the emergency provider, radiologist, cardiologist, respiratory therapist, laboratory company, physician specialty consultants, and the hospital facility itself.  Each of these entities contains unique nuances as to how their services are to be coded and billed.  With each, a document or chart is reviewed, CPT, ICD-9-CM, and HCPCS codes are assigned and a statement or claim is submitted for payment.

Coding and billing for the emergency department facility is a task that requires special knowledge and skills that are apart from the coding and billing performed for the provider.  In addition to CPT, ICD-9-CM and HCPCS codes, a facility coder must know about Ambulatory Payment Classification (APC) codes and Revenue Codes.  Instead of a CMS 1500 form, the facility submits claims using a CMS 1450 Form, also known as a UB-92.  APCs and Revenue Codes will be discussed further in this paper.  Physicians will code and bill for the procedures they perform.  The facility will code and bill for the use of the facility and for supplies and equipment used in the performance of emergency care and services.

The coding and billing of a facility visits starts when the patient arrives for emergency care.  The patient is seen by a hospital registrar who enters the patient into the hospital computer system and obtains information from the patient such as name, address, and insurance information, if available.  It can be said that the hospital registrar is one of the most important members of the hospital team.  If a name, address, emergency information, insurance information, or any other information obtained from the patient, is not verified and entered into the computer correctly, then every claim or statement can end up being denied and unpaid.  The registrar affects billions of dollars of medical care that is rendered every day.  Just as a journey begins with the first step, so does the job of the registrar because their job has a ripple effect that is costly to the industry.

Documentation:  As with any other aspect of coding and billing, documentation is the key to what will be coded and billed to the patient or an insurance company.   In 1995 and 1997, the former Health Care Financing Administration (HCFA), now Centers for Medicare and Medicaid Services, published detailed guidelines for the documentation of evaluation and management (E/M) services.  These guidelines established the criteria for the three key components of an E/M, which are a History, Examination, and Medical Decision Making.  Physicians use these guidelines for documenting, coding, and billing the visit.  Regulatory agencies use these guidelines when conducting audits of the visit.  Unfortunately, these guidelines were designed for the physician and not the facility. 

Hospitals are required to report emergency department visits and critical care services by using the same E/M codes as physicians. The difference between the hospital and provider is that hospitals are required to develop their own internal guidelines or criteria for identifying the different levels of E/M care and map these levels to the physician's CPT codes.  In 2002, CMS recommended an independent expert panel, consisting of the American Hospital Association and the American Health Information Management Association (AHIMA), to develop code definitions and guidelines to be used by CMS  for facility-based E/M services.  This was published in 67 FR 66792.  AHIMA and the American Hospital Association convened an expert panel that developed a standard model for hospitals to report E/M services.   The panel's final report, labeled, "Recommendation for Standardized Hospital Evaluation and Management Coding of Emergency Department and Clinic Services"" was submitted to CMS in June 2003.  A copy of this report is attached to this paper.  67 FR 66792 also recommended that CMS adopt the use of the Florida College of Emergency Physician's facility coding guidelines.  These guidelines, obtained from the American College of Emergency Physician's website, are also attached for review. 

On November 7, 2003, CMS published 42 CFR Parts 410 and 419, Medicare Program, Changes to the Hospital Outpatient Prospective Payment System (HOPPS).  Page 66790 records Policy Decisions and Changes to Hospital Coding for Evaluation and Management Services.  Despite recommendations from AHIMA, ACEP, and the American Hospital Association, CMS continues to recommend hospitals continue to develop their own documentation guidelines for reporting E/M services provided in the emergency department.  Therefore, if a company were to contract with a facility to code and bill for facility emergency care and services, a copy of each facilities documentation guidelines would have to be obtained and available to the coding and billing staff.

Coding:   Facility coding would be similar to coding for the physician.  The facility would use CPT, ICD-9-CM and HCPCS codes.  The codes selected would be drawn from the chart documentation that was prepared by the physician.  In addition, the nurses notes and discharge summary would play a significant part in selecting the proper codes.  When selecting an emergency department E/M code, a history, examination and medical decision are the three key components.  CMS has not released a methodology for facilities to determine the level of an emergency department E/M.  CMS did implement a payment classification for the CPT codes and this classification is called the Ambulatory Payment Classification or APC.  The five emergency department E/M codes are 99281, 99282, 99283, 99284 and 99285.  The two other emergency department E.M codes used are for critical care.  These codes are 99291 and 99292.  Each code is assigned an APC for reimbursement.  They are as follows:

99281 - APC 610 (Low Level Visit)
99282 - APC 610 (Low Level Visit)
99283 - APC 611 (Mid Level Visit)
99284 - APC 612 (High Level Visit)
99285 - APC 612 (High Level Visit)
99291 - APC 620 (High Level Visit)

As you can see, CPT 99281 and 99282; and 99284 and 99285 are in the same APC category respectively.  Therefore if a 99281 or 99282 are selected as the E/M code, the facility will be reimbursed based on the APC level.  The 2005 APC reimbursement is as follows:

If the emergency care physician performed other procedures, such as minor surgery, the surgery codes will also be selected, along with the appropriate APC.  The facility will be reimbursed, not for the procedure that was performed, but for the equipment and supplies used for that procedure.  The following are the CPT codes for a few select surgical procedures performed in the emergency department:

Services performed in the emergency department are defined in the CPT manual.  This manual must be reviewed annually for additions, changes, and deletions to the CPT codes.  For example, in 2006, CPT eliminated the two codes for conscious sedation.  In their place, six new codes were established under a new name called Moderate Conscious Sedation.  When going through the CPT manual there are about 400 distinct procedures that are performed in the emergency department.  These procedures must be listed on the UB-92.  
There are many different types of lacerations repairs, as shown in the table listed above.  There are also injections, and fracture care services that ED physician coders are used to coding for, but are new to facility coders.   Hospitals also list supplies and medications used in the performance of these procedures, but there will be no separate reimbursement made for almost all of them.   ED physician coders don't normally use HCPCS codes when coding for the ED provider, but when coding for the facility, HCPCS codes are constantly used.  Therefore, the coder that wants to code for the facility must learn the requirements for HCPCS coding. 

Status codes are also assigned to APCs.   Surgical procedures that have an APC will have a Status code ""T"" .  This means Medicare will pay the full reimbursement amount for this service. If there is another procedure with a ""T"" status code, Medicare will reimburse 50% of the reimbursement amount.   APCs with an ""S"" or an ""X"" are not subject to the discount for multiple procedures. Facilities must identify physician and nursing procedures performed in the Emergency Department.  This is something that is a requirement under the APC method of reimbursement.   Procedures such as laceration repairs, EKG monitoring, splinting, CPR, etc. must be identified and coded appropriately (including the use of modifiers) in order to be reimbursed by Medicare at the rate for the corresponding APC.   Therefore, both the emergency department nurse and the physician must fully and legibly document everything that was performed and administered during the visit.   

With HCPCS coding, a facility coder will need to know how to code under the CMS Outpatient Prospective Payment System (OPPS). The following represents HCPCS coding to be reported and paid under the OPPS.

*  Revenue codes have not been identified for these procedures, as they can be performed in a number of revenue centers within a hospital, such as emergency room (450), operating room  (360), or clinic (510). Providers are to report these HCPCS codes under the revenue center where the service was performed. The listing of HCPCS codes contained in the chart does not assure coverage of the specific service.

** These codes have been deleted and replaced.  Revenue codes have not been assigned to the new codes.

The selection of diagnosis codes (ICD-9-CM) will still be assigned to document the medical necessity of services provided.  When coding for the physician, emergency department coders will review the documentation for signs, symptoms and diagnosis/diagnoses, for codes to support the CPT codes and to support the emergency visit.  For example, if a patient, with a history of heart problems presents themselves with severe chest pain, the ED physician may order an EKG and lab tests to rule out any serious heart problems.  In the end, the patient may not have had a heart related condition, but was experiencing symptoms related to a duodenal ulcer.  Normally, an EKG and cardiac related lab tests are not ordered for an upset stomach, but the doctor did not know the patient had an upset stomach.  Therefore, it is difficult to justify the visit and the tests that were ordered and performed.  But, when reporting the symptoms experienced by the patient at the time of the visit, it is easy to justify the tests and the visit.   Facility coders are under a slightly different set of rules that are established in the ICD-9-CM manual.  These rules are as follows from the 2006, ICD-9-CM manual.

In determining principal diagnosis the coding conventions in the ICD-9-CM, Volumes I and II take precedence over these official coding guidelines. (See Section IA., A., Conventions for the ICD-9-CM).
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task.

A. Codes for symptoms, signs, and ill-defined conditions
Codes for symptoms, signs, and ill-defined conditions from Chapter 16 are not to be used as principal diagnosis when a related definitive diagnosis has been established.

B. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis.
When there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

C. Two or more diagnoses that equally meet the definition for principal diagnosis.
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

D. Two or more comparative or contrasting conditions.
In those rare instances when two or more contrasting or comparative diagnoses are documented as ""either/or"" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.

E. A symptom(s) followed by contrasting/comparative diagnoses.
When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses.

F. Original treatment plan not carried out.
Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances.

G. Complications of surgery and other medical care.
When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the 996-999 series, an additional code for the specific complication may be assigned.

H. Uncertain Diagnosis.
If the diagnosis documented at the time of discharge is qualified as ""probable"", ""suspected"", ""likely"", ""questionable"", ""possible"", or ""still to be ruled out"", code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to short-term, acute, long-term care and psychiatric hospitals.

It is important that the emergency department physician document ALL diagnoses, so that the facility coder can code them to justify the visit.  If the patient came in with chest pain, or any other type of pain, it should be documented as a diagnosis.  If there are multiple injuries, these should be listed as a diagnosis.  If the patient had chest pain, but the provider only documented a definitive diagnosis of upset stomach, the facility coder cannot report the chest pain, nor can the coder justify the tests ordered for the chest pain.

The nurses notes and discharge summary are the other two key documents that facility coders will use to code the visit.  These documents will show the supplies, medications, and equipment provided to the patient during the visit.  If the physician or nurse is late with the completion of their documentation, this puts a delay on the submission of the facility bill.  The delay in waiting for the completed documentation causes difficulties if the claim is submitted with the documentation as is and once the APC has been submitted and paid.   Medicare makes payments based on the CPT codes submitted by the facility.   Although there is no requirement for physician documentation to support the facility visit, the physician documentation adds to the coding in areas where nursing documentation is lacking. Facility coders look to physicians to appropriately identify their own procedures in order to assign appropriate codes.

Revenue Codes:  In addition to the CPT and APC, the claim must also be submitted using revenue codes.  Revenue codes are used to bill outpatient hospital facility services.  In some instances, a HCPCS code is required in addition to the revenue code.  Examples of revenue codes are as follows (The asterick (*) is not part of the code.  It tells the coder additional information:

IV Therapy
260 General classification
261 Infusion pump
262 IV therapy/pharmacy services
263 IV therapy/drug/supply delivery
264 IV therapy/supplies
269 Other IV therapy

Medical/Surgical Supplies and Devices
270 General classification
271 Nonsterile supply
272 Sterile supply
273 Take-home supplies
274* Prosthetic/orthotic devices  HCPCS code required 
275 Pacemaker
276 Intraocular lens
277 Oxygen - take-home   Not a benefit
278* Other implants    HCPCS code required
279* Other supplies/devices  HCPCS code required
620* Medical/surgical supplies  HCPCS code required
621 Supplies incident to radiology
622 Supplies incident to other diagnostic services
623 Surgical dressings
624 FDA investigational devices  Not a benefit

Laboratory
300* General classification   HCPCS code required
301* Chemistry    HCPCS code required
302* Immunology    HCPCS code required
303* Renal patient (home)   HCPCS code required
304* Nonroutine dialysis   HCPCS code required
305* Hematology    HCPCS code required
306* Bacteriology and microbiology HCPCS code required
307* Urology    HCPCS code required
309* Other laboratory   HCPCS code required

Radiology-Diagnostic
320* General classification   HCPCS code required
321* Angiocardiography   HCPCS code required
322* Arthrography    HCPCS code required
323* Arteriography    HCPCS code required
324* Chest X-ray    HCPCS code required
329* Other diagnostic radiology  HCPCS code required

Other Imaging Services
400* General classification   HCPCS code required
401* Diagnostic mammography  HCPCS code required
402* Ultrasound    HCPCS code required
403* Screening mammography  HCPCS code required
404* Positron emission tomography HCPCS code required
409* Other imaging services  HCPCS code required

Respiratory Services
410 General classification
412 Inhalation services
413 Hyperbaric oxygen therapy
419* Other respiratory services  HCPCS code required

Physical Therapy
420* General classification   HCPCS code required
421* Visit charge    HCPCS code required
422* Hourly charge    HCPCS code required
423* Group rate    HCPCS code required
424* Evaluation or re-evaluation  HCPCS code required
429* Other physical therapy  HCPCS code required

Emergency Room
450 General classification
456 Urgent care
459 Other emergency room

Pulmonary Function
460* General classification   HCPCS code required
469* Other pulmonary function  HCPCS code required

EKG/ECG (Electrocardiogram)
B-730*  General classification  HCPCS code required
B-731*  Holter monitor   HCPCS code required
B-732*  Telemetry    HCPCS code required
B-739*  Other EKG/ECG   HCPCS code required

These are just a few of the many revenue codes used to bill facility services.  When billing Medicaid or a commercial insurance company, it is best that the coder have the provider manual to see if there are any revenue codes specific to Medicaid or the commercial carrier.

Claim:   Providers use a CMS 1500 form to submit claims for their services.  Facilities normally use a CMS form 1450 (UB-92) to submit claims.  All entries on a UB-92 are made in a field called a Form Locator or FM.  All Form Locators are assigned a number.  For example Form Locator 67 is called FL67 and FL67 is the diagnosis code.  Only an original UB 92 can be submitted for payment.  As with the CMS 1500 form, not all fields are necessary when billing for the emergency department facility.

The following are the fields used for submitting a claim for the emergency department:

FL1:  Name, Address and Phone Number of the Billing Provider. 

FL2:  Patient Control Number or Office Account Number.  This field can be up to 20 characters in length.

FL4:  Type of Bill.  This is usually a 3 digit number.  The first digit is the type of facility.  The second digit is the type of care.  The third digit is carrier specific and defines the particular episode of care.  It is referred to as a frequency code.  The following is the code structure:

First Digit: Type of Facility
1 - Hospital
2 - Skilled Nursing Facility
3 - Home Health
4 - Religious Non Medical (Hospital)
6 - Intermediate Care
7 - Clinic or Hospital Based Renal Dialysis Facility
8 - Special Facility or Hospital ASC surgery

Second Digit:  Bill Classification
1 - Inpatient (Part A)
2 - Inpatient (Part B Only)
3 - Outpatient
4 - Other Part B
5 - Intermediate Care Level 1
6 - Intermediate Care Level II
8 - Swing Beds

Third Digit - Frequency
0 - Nonpayment/Zero Claims: Use this code when you do not anticipate payment
     from the payor for the bill, but are informing the
     payor about a period of non-payable confinement or
     termination of care.

1 - Admit Through Discharge: Use this code for a bill encompassing an entire
     inpatient confinement or course of outpatient
     treatment for which you expect payment from the
     payor or which will update the deductible for
     inpatient or Part B claims when Medicare is
     secondary to EGHP (Employer Group Health Plan).

2 - Interim First Claim:  Use this code for the first of an expected series of
     bills for which utilization is chargeable or which
     will update inpatient deductible for the same
     confinement or course of treatment.

3 - Interim Continuing Claims: Use this code when a bill for which utilization is
     chargeable for the same confinement or course of
     treatment had already been submitted and further
     bills are expected to be submitted later.

4 - Interim Last Claim: Use this code for a bill for which utilization is chargeable and which is their last of a series for this confinement or course of treatment. 

5 - Late Charge Only: Use this code for outpatient claims only. 

7 - Replacement of Prior Claim: Use this code to correct a previously submitted bill. 

8 - Void/Cancel of a Prior Claim: Use this code to indicate this bill is an exact duplicate of an incorrect bill previously processed. 

For a patient who was seen in the emergency department and was discharged, the code
used in this Form Locator would be 131

FL5:  Federal Tax ID Number

FL6:  Statement Covers Period:  The provider enters the beginning and ending dates of
the period included on the bill in numeric fields (MMDDYYYY).  The payors will use
the ""From"" date to determine timely filing.

FL12:  Patient Name

FL13:  Patient Address

FL14:  Patient Date of Birth

FL15:  Patient Sex

FL16:  Patient Marital Status:
S = Single
M = Married
P = Life Partner
X = Legally Separated
D = Divorced
W = Widowed
U = Unknown

FL22:  Status:  This is required for all outpatient services.  This is a two digit code:
01 - Routine Discharge
02 - Discharge/Transfer to another hospital for inpatient care. 
03 - Discharged/Transfer to Skilled Nursing Facility
04 - Discharged/Transfer to Intermediate care facility.
05 - Discharged/Transfer to another institution not elsewhere defined.
06 - Discharged/Transfer to home under care of organized heath service organization.
07 - Left Against Medical Advice or discontinued care
09 - Admitted as an inpatient to this hospital
20 - Expired or did not recover
30 - Still a patient or expected to return for outpatient services
40 - Expired at home
41 - Expired in a medical facility
42 - Expired, place unknown
43 - Discharged to federal hospital
50 - Hospice - Home
51 - Hospice - Medical facility

FL23:  Medical Record Number

FL 24-30:  Condition Codes:  This entry is required and the provider enters the
corresponding code to describe any of the following conditions or events that apply to
this billing period.  These are just a few of the codes that could be used.  More than one
code can be used, depending on the circumstances.:

02:  Condition is employment related
03:  Patient covered by insurance not reflected here.
04:  Information Only Bill.
05:  Lien has been filed.
06:  End Stage Renal Disease patient in first 30 months of entitlement covered by EGHP
07:  Treatment of Non-Terminal Condition for Hospice Patient.
08:  Beneficiary would not provide information concerning other insurance coverage.
09:  Neither patient or spouse is employed.
10:  Patient and/or spouse is employed but no EGHP coverage
11:  Disabled beneficiary but no EGHP
15:  Clean claim delayed by CMS processing system
17:  Patient is homeless
18:  Maiden name retained.
19:  Child retains mother's name
20:  Beneficiary requested billing.
21:  Billing for denial notice
26:  VA eligible patient chooses to receive services in Medicare certified facility.
28:  Patient and/or spouse EGHP is secondary to Medicare.
29:  Disabled beneficiary and/or family LGHP is secondary to Medicare.
31:  Patient is a full time day student
32:  Patent is a student (Cooperative/Work study program)
33:  Patient is a full time night student.
34:  Patient is a part time student.
62:  PIP bill
D0:  Changes to Date of Service
D1:  Changes to Charges
D2:  Changes to Revenue Codes/HCPCS/Rate Codes
D4:  Changes to ICD-9-CM or Procedure Code
D5:  Cancel to correct HICN or Provider ID
D6:  Cancel only to repay a duplicate claim or OIG overpayment.
D7:  Change to Make Medicare the Secondary Payer.
D8:  Change to Make Medicare the Primary Payer.
E0:  Change in Patient Status
G0:  Distinct Medical Visit, for example, Patient going to ER twice in same day.  One for
        broken arm, second for chest pain.

FL 32-35:  Occurrence Codes:  The provider enters the code(s) and associated date(s)
                                                   defining specific event(s) relating to this billing period. 
                                                   Event codes are two alpha-numeric digits and dates are
                                                   six numeric digits (MMDDYY).  When occurrence code
                                                   01-04 and 24 are used, the provider must make sure the
                                                   entry includes the appropriate value code in FL 39-41, if
                                                   there is another payer involved.  Code Structure (This is
                                                   just a sample of the codes available):

01:  Accident/Medical Coverage  (Provide the date of accident/injury)
02:  No Fault Insurance involved including Auto Accident (Other).
03:  Accident/Tort Liability
04:  Accident Employment Related
05:  Accident/No Medicare or Liability Coverage
06:  Crime Victim
10:  Last menstrual period (Used only for maternity related condition)
11:  Onset of symptoms/Illness (The date when the patient first became aware)
18:  Date of Retirement Patient/beneficiary.
19:  Date of Spouse retirement
20:  Guarantee of Payment
24:  Date insurance denied
25:  Date benefits terminated by Primary Payer
A1:  Birthdate, Insured A
A2:  Effective Date Insured A Policy
A3:  Benefits exhausted
B1:  Birthdate Insured B
B2:  Effective Date Insured B Policy
B3:  Benefits Exhausted
C1:  Birthdate, Insured C
C2:  Effective Date Insured C Policy
C3:  Benefits Exhausted

FL37:  Internal Control Number (ICN)/Document Control Number (DCN):  The provider
enters the control number assigned to the original bill.  This field is used with
adjustment requests or voiding a paid claim..  When requesting an adjustment to a
 previously processed claim, the provider inserts the ICN/DCN of the claim to be
adjusted.  Payer A's ICN/DCN should be shownon line A in FL 37.  Payer's B
and C's ICN/DCN will be in line B and C respectively.

FL 39-41:  Value Codes and Amounts:   Code(s) and related dollar or unit amount(s)
identify data of a monetary nature that are
necessary for the processing of this claim. 
The codes are alpha-numeric digits and each
value allows up to nine numeric digits (0000000.00).  Negative amounts are not allowed in FL 41.  Whole numbers or
non-dollar amounts are right justified to the
left of the dollars and cents delimiter.  If
more than one value code is shown for a
billing period, codes are shown in ascending
numeric sequence. 

Value Codes  The following are just a sample of the codes used:

14:  No-fault, including auto/other insurance.  This code indicates the amount
shown is that portion of a higher priority no-fault insurance payment including auto/other insurance payment made on behalf of a Medicare beneficiary that the provider is applying to covered Medicare charges on this bill.

15:  Workers' Compensation.  This code indicates that the amount shown is that
portion of a higher workers' compensation insurance payment made on behalf of
a Medicare beneficiary that you are applying for covered Medicare charges on
this bill.  When the provider received no payment or a reduced payment because
of a failure to file a proper claim, enter the amount that would have been payable
had you filed a proper claim.

44:   Amount provider agreed to accept from Primary Payer when this amount is
less than charges but higher than payment received.

45:    Accident Hour:  The hour when an accident occurred. 

A1:  Deductible Payer A.

A2:  Coinsurance Payer A.

A3:  Estimated responsibility Payer A.

A4:  Covered Self Administered Drugs, Emergency

A7:  Co-payment A.

FL42 - 49 are similar to Blocks 24 of