Billing & Coding Emergency Department Procedures &
Description: Billing Coding Emergency Department Procedures Point-of-Care Ultrasound Elizabeth Barrall Werley, MD Program Director Assistant Professor of Emergency Medicine Penn State Health Reimbursement Cognitive work Evaluation and Management
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slide1. Billing & Coding Emergency Department Procedures & Point-of-Care Ultrasound Elizabeth Barrall Werley, MD
Program Director
Assistant Professor of Emergency Medicine
Penn State Health<br>
slide2. Reimbursement Cognitive work
Evaluation and Management (E/M) codes
99281 – 99285
Critical Care codes
Procedures
Reimbursement may be higher than E/M service<br>
slide3. CPT Codes Current Procedural Terminology (CPT)
Maintained by the AMA
Select few E/M codes in Emergency Medicine
Specific codes for specific procedures<br>
slide4. 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<br>
slide5. 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)<br>
slide6. 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<br>
slide7. Document (when applicable):
Procedure performed
Indication
Location
Laterality
Complexity
Technique
Supplies used General Approach to Procedures<br>
slide8. Many procedures only have 1 CPT code
Other procedures can have multiple options General Approach to Procedures<br>
slide9. Special circumstance related to a procedure
-22 Increased Procedural Services
-50 Bilateral Procedure
-51 Multiple Procedures
-53 Discontinued Procedure Modifiers<br>
slide10. 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 Modifiers<br>
slide11. Lacerations/Wound Repair RVU ↑
Complexity of wound
Simple, intermediate, complex
Length of repair
Measure, don’t estimate
Details matter<br>
slide12. Lacerations/Wound Repair Comparison billing for a 2.0cm chest wound Verhovshek J. Wound Repair Closure Coding Made Simple. American Academy of Professional Coders.<br>
slide13. Lacerations/Wound Repair Grouped together (one CPT code)
Same anatomic site
Same complexity
Coded individually
Different anatomic groupings
Varying complexity<br>
slide14. 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<br>
slide15. 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<br>
slide16. Lacerations/Wound Repair Tissue Adhesive or Staples
Use same CPT code for other wound repair
Rare exception for Medicare subgroups<br>
slide17. Lacerations/Wound Repair Priority in which wound repairs are coded
Complexity
Anatomic site
Size<br>
slide18. Lacerations/Wound Repair Factors that impact coding
Complexity of closure
Extent of cleaning
Debridement
Revision of wound edges
Foreign body removal<br>
slide19. Lacerations/Wound Repair Additional Diagnoses
Do not increase E/M services themselves
Do support the E/M service documented<br>
slide20. Abscess I&D Simple
Single
Small collection of purulence<br>
slide21. Abscess I&D Complex or Multiple (any of 3)
Multiple
Probing/loculations
Packing
Sub-fascial – more complicated to code<br>
slide22. 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<br>
slide23. Fracture/Dislocation Care Fracture-management services
Restorative Care
Definitive Care
No splint code
Splinted but not fracture-care services?
Splint code<br>
slide24. Fracture/Dislocation Care E/M service vs fracture/dislocation code
Separate medical service
Detailed history and exam
Supports higher level E/M service<br>
slide25. Fracture/Dislocation Care High RVUs
Associated procedures?
Procedural sedation
X-ray interpretation<br>
slide26. Procedural Sedation Solo completion or assisting others
Only direct patient contact counts<br>
slide27. Procedural Sedation Defined by time
Initial code
0-30 minutes, met at ≥ 16 minutes
Additional time
15 minute intervals, met at ≥ 8 minutes<br>
slide28. Point-of-Care Ultrasound What is needed:
Interpretation
Medical necessity/Indication
Images saved
Diagnostic and procedural guidance<br>
slide29. 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<br>
slide30. 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<br>
slide31. Point-of-Care Ultrasound FAST/E-FAST
Limited abdominal US
Limited transthoracic echocardiogram
± Limited thoracic US<br>
slide32. Point-of-Care Ultrasound Pelvic US – based on pregnancy status
Transabdominal
Obstetric eval
Non-obstetric eval
Transvaginal
Only “complete” option
Must use modifier<br>
slide33. Point-of-Care Ultrasound Procedural guidance
Same rules apply for documentation
Procedure + US guidance – separate CPT codes<br>
slide34. Point-of-Care Ultrasound Procedural guidance
Select procedures – CPT code includes US
Thoracentesis
Paracentesis
Arthrocentesis<br>
slide35. 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<br>
slide36. Common Procedures List generated utilizing 2019 National Physician Fee Schedule Relative Value File, published by CMS.<br>
slide37. Common Procedures List generated utilizing 2019 National Physician Fee Schedule Relative Value File, published by CMS.<br>
slide38. Common Procedures List generated utilizing 2019 National Physician Fee Schedule Relative Value File, published by CMS.<br>
slide39. 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/<br>
slide40. 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/<br>
slide41. 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<br>
Program Director
Assistant Professor of Emergency Medicine
Penn State Health<br>
slide2. Reimbursement Cognitive work
Evaluation and Management (E/M) codes
99281 – 99285
Critical Care codes
Procedures
Reimbursement may be higher than E/M service<br>
slide3. CPT Codes Current Procedural Terminology (CPT)
Maintained by the AMA
Select few E/M codes in Emergency Medicine
Specific codes for specific procedures<br>
slide4. 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<br>
slide5. 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)<br>
slide6. 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<br>
slide7. Document (when applicable):
Procedure performed
Indication
Location
Laterality
Complexity
Technique
Supplies used General Approach to Procedures<br>
slide8. Many procedures only have 1 CPT code
Other procedures can have multiple options General Approach to Procedures<br>
slide9. Special circumstance related to a procedure
-22 Increased Procedural Services
-50 Bilateral Procedure
-51 Multiple Procedures
-53 Discontinued Procedure Modifiers<br>
slide10. 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 Modifiers<br>
slide11. Lacerations/Wound Repair RVU ↑
Complexity of wound
Simple, intermediate, complex
Length of repair
Measure, don’t estimate
Details matter<br>
slide12. Lacerations/Wound Repair Comparison billing for a 2.0cm chest wound Verhovshek J. Wound Repair Closure Coding Made Simple. American Academy of Professional Coders.<br>
slide13. Lacerations/Wound Repair Grouped together (one CPT code)
Same anatomic site
Same complexity
Coded individually
Different anatomic groupings
Varying complexity<br>
slide14. 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<br>
slide15. 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<br>
slide16. Lacerations/Wound Repair Tissue Adhesive or Staples
Use same CPT code for other wound repair
Rare exception for Medicare subgroups<br>
slide17. Lacerations/Wound Repair Priority in which wound repairs are coded
Complexity
Anatomic site
Size<br>
slide18. Lacerations/Wound Repair Factors that impact coding
Complexity of closure
Extent of cleaning
Debridement
Revision of wound edges
Foreign body removal<br>
slide19. Lacerations/Wound Repair Additional Diagnoses
Do not increase E/M services themselves
Do support the E/M service documented<br>
slide20. Abscess I&D Simple
Single
Small collection of purulence<br>
slide21. Abscess I&D Complex or Multiple (any of 3)
Multiple
Probing/loculations
Packing
Sub-fascial – more complicated to code<br>
slide22. 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<br>
slide23. Fracture/Dislocation Care Fracture-management services
Restorative Care
Definitive Care
No splint code
Splinted but not fracture-care services?
Splint code<br>
slide24. Fracture/Dislocation Care E/M service vs fracture/dislocation code
Separate medical service
Detailed history and exam
Supports higher level E/M service<br>
slide25. Fracture/Dislocation Care High RVUs
Associated procedures?
Procedural sedation
X-ray interpretation<br>
slide26. Procedural Sedation Solo completion or assisting others
Only direct patient contact counts<br>
slide27. Procedural Sedation Defined by time
Initial code
0-30 minutes, met at ≥ 16 minutes
Additional time
15 minute intervals, met at ≥ 8 minutes<br>
slide28. Point-of-Care Ultrasound What is needed:
Interpretation
Medical necessity/Indication
Images saved
Diagnostic and procedural guidance<br>
slide29. 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<br>
slide30. 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<br>
slide31. Point-of-Care Ultrasound FAST/E-FAST
Limited abdominal US
Limited transthoracic echocardiogram
± Limited thoracic US<br>
slide32. Point-of-Care Ultrasound Pelvic US – based on pregnancy status
Transabdominal
Obstetric eval
Non-obstetric eval
Transvaginal
Only “complete” option
Must use modifier<br>
slide33. Point-of-Care Ultrasound Procedural guidance
Same rules apply for documentation
Procedure + US guidance – separate CPT codes<br>
slide34. Point-of-Care Ultrasound Procedural guidance
Select procedures – CPT code includes US
Thoracentesis
Paracentesis
Arthrocentesis<br>
slide35. 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<br>
slide36. Common Procedures List generated utilizing 2019 National Physician Fee Schedule Relative Value File, published by CMS.<br>
slide37. Common Procedures List generated utilizing 2019 National Physician Fee Schedule Relative Value File, published by CMS.<br>
slide38. Common Procedures List generated utilizing 2019 National Physician Fee Schedule Relative Value File, published by CMS.<br>
slide39. 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/<br>
slide40. 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/<br>
slide41. 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<br>