Emergency Department Coding & Reimbursement Alert

Understand the Difference Between Facility Coding and Professional Coding to Resolve Payer Conflicts

- Published on Thu, Apr 01, 1999
Although they are coding for the same ED visits, hospital information coders and emergency physician practice coders rarely speak the same language when it comes to reporting the procedures and services delivered. “Hospital coding and physician coding are two separate worlds,” states Charlene Day, BS, CMA, CMM, practice manager for Team Physicians of Arizona, an emergency medicine practice group in Phoenix, AZ. “It is often very confusing for a hospital coder and a physician coder to even discuss coding, and it’s nearly impossible for health plans to understand the concept—something I am dealing with now.” But, with Medicare shifting hospital reimbursement for ED services into one lump sum payment and managed care demanding more cost accountability for all emergency services, ED professional coders and facility coders will have to work together if the hospital and emergency physician group expect to survive. Why Should You Care? Unlike other specialties, emergency medicine often blurs the line between inpatient (hospital) and outpatient (often thought of as office-based) services. The ED physicians work at the hospital but are not hospital employees. They may bill for their services separately. They are not reimbursed for services provided by the nurses, who are employed by the hospital, and they do not bill for supplies, as these are provided by the facility as well. When reporting ED services, the hospital seeks reimbursement for use of the actual facility—the space in the emergency department—used by the physician, the supplies used, and the services delivered by the hospital employees. In the past, the facility side of ED coding and professional side rarely interfaced, says Day. The physician group billed third-party payers for its services; the insurance plans reimbursed the hospital a percentage of its charges in a separate payment. However, in recent years, third-party payers, particularly managed care, have begun to scrutinize the cost of ED services. Many of them do not want to receive two bills for the same visit and expect the physician group to add its charges to the hospital bill, says Day. And, she indicates, many health plan representatives don’t understand the difference between facility and professional ED coding. They will often question ED professional coders about any differences reported by the hospital information department, and vice versa. Facility Coding vs. Professional Coding:
What’s the Difference? 1. Professional coders must follow CPT. When a patient presents to the ED for care, emergency physicians must follow strict rules for documenting and coding their evaluation and management (E/M) services and any procedures they perform. “Physicians are mandated to use the Health Care Financing Administration (HCFA) guidelines along with CPT-4 to code their records,” says Day. CPT and HCFA have set rules detailing which services warrant a particular [...]

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