Billing, Coding, and Reimbursement in Emergency Department Procedures

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Explore the world of billing, coding, and reimbursement in emergency department procedures, covering topics such as E/M codes, critical care codes, CPT codes, RVUs, general approach to procedures, and modifiers. Understand the nuances of documenting procedures and maximizing reimbursement potential.


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Billing, Coding, and Reimbursement in Emergency Department Procedures

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  1. Billing & Coding Emergency Department Procedures & Point-of-Care Ultrasound ELIZABETH BARRALL WERLEY, MD PROGRAM DIRECTOR ASSISTANT PROFESSOR OF EMERGENCY MEDICINE PENN STATE HEALTH

  2. Reimbursement Cognitive work Evaluation and Management (E/M) codes 99281 99285 Critical Care codes Procedures Reimbursement may be higher than E/M service

  3. CPT Codes Current Procedural Terminology (CPT) Maintained by the AMA Select few E/M codes in Emergency Medicine Specific codes for specific procedures

  4. CPT vs CMS Center for Medicare and Medicaid Services (CMS) Differences between CPT and CMS for E/M Dependent upon group and payer mix CPT guidelines apply if non-participatory with a payer

  5. RVUs Relative Value Unit Value assigned to E/M codes, CPT codes In 2019, 1 RVU = $36.04 Total RVU components: Physician Work Practice Expense (facility) Liability Insurance (malpractice)

  6. General Approach to Procedures In addition to E/M services Document each procedure individually Remember, you do not get reimbursed for what you do, you get paid for what you document about what you do! ACEP Coding and Reimbursement Pearls

  7. General Approach to Procedures Document (when applicable): Procedure performed Indication Location Laterality Complexity Technique Supplies used

  8. General Approach to Procedures Many procedures only have 1 CPT code Other procedures can have multiple options

  9. Modifiers Special circumstance related to a procedure -22 Increased Procedural Services -50 Bilateral Procedure -51 Multiple Procedures -53 Discontinued Procedure

  10. Modifiers Special circumstance related to a procedure -76 Repeat Procedure or Service by Same Physician or other qualified Health Care professional -77 Repeat Procedure by Another Physician or other qualified Health care Professional Anatomic Modifiers Performance Measurement Modifiers

  11. Lacerations/Wound Repair RVU Complexity of wound Simple, intermediate, complex Length of repair Measure, don t estimate Details matter 2.5 cm 2.6cm 7.5cm 7.6cm 12.5cm 12.6cm 20.0cm 20.1cm 30.0cm > 30.0 cm

  12. Lacerations/Wound Repair Comparison billing for a 2.0cm chest wound CPT Code Complexity Location Size *Physicia n work RVU *Approx. Medicare payment 12001 Simple Scalp, neck, axillae, external genitalia, trunk, extremities (incl. hands/feet) 2.5cm 0.84 $21 12031 Intermed. Scalp, neck, axillae, external genitalia, trunk, extremities (excl. hands/feet) 2.5cm 2.0 $50 13100 Complex Trunk 1.1-2.5cm 3.0 $75 Verhovshek J. Wound Repair Closure Coding Made Simple. American Academy of Professional Coders.

  13. Lacerations/Wound Repair Grouped together (one CPT code) Same anatomic site Same complexity Coded individually Different anatomic groupings Varying complexity

  14. Lacerations/Wound Repair Simple Superficial One-layer closure Anatomic groupings Scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands or feet) Face, ears, eyelids, nose, lips and/or mucous membranes

  15. Lacerations/Wound Repair Intermediate Layered closure (skin + subcutaneous tissue) Single-layer closure but contaminated 3 different anatomic groupings Complex Multi-layer Extensive tissue damage and repair

  16. Lacerations/Wound Repair Tissue Adhesive or Staples Use same CPT code for other wound repair Rare exception for Medicare subgroups

  17. Lacerations/Wound Repair Priority in which wound repairs are coded Complexity Anatomic site Size

  18. Lacerations/Wound Repair Factors that impact coding Complexity of closure Extent of cleaning Debridement Revision of wound edges Foreign body removal

  19. Lacerations/Wound Repair Additional Diagnoses Do not increase E/M services themselves Do support the E/M service documented

  20. Abscess I&D Simple Single Small collection of purulence

  21. Abscess I&D Complex or Multiple (any of 3) Multiple Probing/loculations Packing Sub-fascial more complicated to code

  22. Fracture/Dislocation Care Fracture and/or Dislocation codes Defined as surgical global care procedures Closed treatment of fracture without manipulation Closed treatment of fracture with manipulation Closed treatment of dislocation with fracture with manipulation Closed treatment of dislocation without fracture, with manipulation Open vs closed fracture open vs closed treatment

  23. Fracture/Dislocation Care Fracture-management services Restorative Care Definitive Care No splint code Splinted but not fracture-care services? Splint code

  24. Fracture/Dislocation Care E/M service vs fracture/dislocation code Separate medical service Detailed history and exam Supports higher level E/M service

  25. Fracture/Dislocation Care High RVUs Associated procedures? Procedural sedation X-ray interpretation

  26. Procedural Sedation Solo completion or assisting others Only direct patient contact counts

  27. Procedural Sedation Defined by time Initial code 0-30 minutes, met at 16 minutes Additional time 15 minute intervals, met at 8 minutes

  28. Point-of-Care Ultrasound What is needed: Interpretation Medical necessity/Indication Images saved Diagnostic and procedural guidance

  29. Point-of-Care Ultrasound Defined by body area, not procedure Limited vs Complete Exams Complete Limited Most c/w EM practice Exception: TV US No limited option

  30. Point-of-Care Ultrasound Modifiers common to ED POCUS -26: professional component Professional services only VS professional AND technical services -76: Repeat procedure by same person -77: Repeat procedure different different person -52: Service reduction

  31. Point-of-Care Ultrasound FAST/E-FAST Limited abdominal US Limited transthoracic echocardiogram Limited thoracic US

  32. Point-of-Care Ultrasound Pelvic US based on pregnancy status Transabdominal Obstetric eval Non-obstetric eval Transvaginal Only complete option Must use modifier

  33. Point-of-Care Ultrasound Procedural guidance Same rules apply for documentation Procedure + US guidance separate CPT codes

  34. Point-of-Care Ultrasound Procedural guidance Select procedures CPT code includes US Thoracentesis Paracentesis Arthrocentesis

  35. Point-of-Care Ultrasound Procedural guidance CPT 76937 Vascular US guidance Static vs. dynamic Can only bill for dynamic Images obtained when available Post-procedure confirmation

  36. Common Procedures Procedure CPT Code RVU Approx. Payout Endotracheal Intubation 31500 4.07 $146.68 Diagnostic Fiberoptic Laryngoscopy (w/o intubation) 31575 1.91 Intraosseous Line 36680 1.69 $60.91 Central Line 36556 2.45 $88.30 Cardioversion 92960 3.13 $112.80 Chest Tube 32551 4.53 $163.26 CPR 5.35 Lumbar Puncture 62270 2.23 $80.37 Thoracentesis (including US) List generated utilizing 2019 National Physician Fee Schedule Relative Value File, published by CMS. 32555 3.22 $116.05

  37. Common Procedures Procedure CPT Code RVU Approx. Payout NG/OG Tube 51702 0.63 $22.70 G Tube Replacement (not revision) 43762 1.09 $39.28 Foley Catheter Insertion (RN unsuccessful, by physician) 51702 0.73 $26.31 Suprapubic Catheter (place/change cystostomy tube) 51705 1.50 $54.06 Corneal FB removal (w/slit lamp) 65222 1.48 Corneal FB removal (w/o slit lamp) List generated utilizing 2019 National Physician Fee Schedule Relative Value File, published by CMS. 1.19

  38. Common Procedures Procedure CPT Code RVU Approx. Payout Simple/Single Abscess I&D 10060 2.81 $101.27 Complex/Multiple Abscess I&D 10061 5.16 $185.96 Epistaxis Control Anterior, simple (silver nitrate) 30901 1.62 Expistaxis Control Anterior, complex (packing, nasal tampon) 30903 2.25 Epistaxis Control Posterior (packing) 30905 3.01 List generated utilizing 2019 National Physician Fee Schedule Relative Value File, published by CMS.

  39. References 1. Emergency department coding and reimbursement: a physician s guide. LOGIX Health. 2. What every graduating resident needs to know about reimbursement. American College of Emergency Physicians. Updated March 2019. https://www.acep.org/administration/reimbursement/what-every-graduating-resident- needs-to-know-about-reimbursement/ 3. CPT codes, guidelines & additional resources. American Medical Association. https://www.ama-assn.org/amaone/cpt-current-procedural-terminology 4. Evaluation and management documentation requirements CMS vs. CPT. American College of Emergency Physicians. https://www.acep.org/administration/reimbursement/documentation- guidelines/evaluation-and-management-documentation-requirements--cms-vs.-cpt/ 5. Approach to emergency department coding FAQ. American College of Emergency Physicians. https://www.acep.org/administration/reimbursement/reimbursement- faqs/approach-to-emergency-department-coding-faq/

  40. References 6. Coding and reimbursement pearls. American College of Emergency Physicians. https://www.acep.org/administration/reimbursement/coding-and-reimbursement- pearls/#laceration 7. Modifier dictionary FAQ. American College of Emergency Physicians. Updated April 12 2017. https://www.acep.org/administration/reimbursement/reimbursement- faqs/modifier-dictionary-faq/ 8. Verhovshek J. Wound repair closure coding made simple. American Academy of Professional Coders. https://www.aapc.com/blog/26267-closure-coding-made-simple/ 9. Magdziarz D. Reimbursement 2019: a field-guide for physicians in the trenches. American College of Osteopathic Emergency Physicians. https://acoep.org/ss19/wp- content/uploads/2019/03/Reimbursement-2019_-A-Field-Guide-for-Physicians-in-the- Trenches_Magdziarz.pdf 10. Verhovshek J. Coding abscess procedures. American Academy of Professional Coders. https://www.aapc.com/blog/37219-coding-abscess-procedures/

  41. References 11. Orthopedic fracture/dislocation management FAQ. American College of Emergency Physicians. Updated May 16, 2015. https://www.acep.org/administration/reimbursement/reimbursement-faqs/orthopedic- fracture--dislocation-management-faq/#question0 12. Verhovshek J. Proper coding for endotracheal intubation. American Academy of Professional Coders. https://www.aapc.com/blog/28116-proper-coding-for-endotracheal- intubation/ 13. Ultrasound FAQ. American College of Emergency Physicians. Updated September 2019. https://www.acep.org/administration/reimbursement/reimbursement- faqs/ultrasound-faqs/#question10

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