Expert Article: ED Facility Coding Criteria Considerations and Pitfalls

The Centers for Medicare and Medicaid Services (CMS) implemented the Outpatient Prospective Payment System (OPPS) in January 2000 to pay for designated outpatient hospital items and services. Since that time, hospital emergency departments have struggled to adapt to instructions issued by CMS that each hospital develop its own facility coding criteria that define a method for assigning ED visit levels 99281 through 99285 for every patient encounter in an ED. While many hospitals thought that CMS would eventually publish its own criteria, this has not occurred. 


In the 2008 Outpatient Prospective Payment System (OPPS) Final Rule, CMS issued the following eleven principles to guide hospitals in the development of their own unique criteria, stating that the criteria should:

  • Reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.

  • Be based on hospital facility resources, not on physician resources.

  • Be clear to facilitate accurate payments and be usable for compliance purposes and audits.

  • Meet the HIPAA requirements.

  • Only require documentation that is clinically necessary for patient care.

  • Not facilitate upcoding or gaming.

  • Be written or recorded, well-documented, and provide the basis for selection of a specific code.

  • Be applied consistently across patients in the emergency department to which they apply.

  • Not change with great frequency.

  • Be readily available for MAC review.

  • Result in coding decisions that could be verified by other hospital staff, as well as outside sources.


The 2008 Final Rule (FR) also shed light on the question of “double dipping” and whether separately payable services – such as CPT procedure codes that define laceration repairs, infusions and injections, etc. – could be used as a method of defining E/M levels of service 99281 through 99285. The 2008 FR stated, “In the absence of national visit guidelines, hospitals have the flexibility to determine whether or not to include separately payable services as a proxy to measure hospital resource use that is not associated with those separately payable services. The costs of hospital resource use associated with those separately payable services would be paid through separate OPPS payment for the other services.”


Since the initiation of the FR, hospital emergency departments have developed different methods of assigning EM Levels 99281 through 99285, with some hospitals allocating a “weight” or point system to tasks performed by hospital staff in an ED. Still other facilities have utilized the “Emergency Department Facility Coding Guidelines” developed by The American College of Emergency Physicians (ACEP). In order to develop its guidelines, ACEP consulted emergency physicians, nurses, and coders, who were very familiar with the functional workings of EDs, and the hospital resources expended to care for ED patients.


BSA Healthcare agrees that ACEP’s Emergency Department Facility Coding Guidelines appropriately reflect facility levels and follow the eleven principles issued by the 2008 FR. That said, after providing numerous reviews of hospital emergency department facility coding, we would like to offer a few suggestions to ensure your coders apply ACEP’s criteria consistently.


Via our auditing services, it has been revealed that many hospitals use the ACEP criteria without first defining certain terms included within the criteria, or developing policies that support coders in consistent, accurate E/M code choice. The following points are intended to help hospital and coding company compliance personnel determine if additional policies, procedures, or coder education are warranted.

  1. The ACEP guidelines include good instructions for use of their criteria. The guidelines also recognize that each ED is unique, stating, “Facilities using the guidelines should ensure they are appropriate for use and reflect the salient circumstances of their institution.  Some facilities have found it helpful to adapt the guidelines to the particular needs of their institution.” For instance, administrators who are responsible for approving the ACEP facility criteria for an ED should consider whether their hospital treats a large population of children, pregnant, psychiatric, or trauma patients. If so, additions to the criteria will need to be incorporated that ensure the criteria appropriately reflects resource utilization for these patients. 


  1. In every level of service, the ACEP criteria lists “Discussion of Discharge Instructions” as a determination of a level of service. Providers and nurses must appropriately document the level of discharge instructions given to each patient to allow a coder to appropriately conform to this instruction.


For example, do coders have access to a policy that determines when ibuprofen is offered as an over-the-counter medication, and what strength is considered prescription strength? 


How do coders interpret “multiple prescription medications and/or home therapies”, which is defined as “complex” discharge, by ACEP? Do coders define multiple prescriptions as “more than one prescription?” If so, does an encounter during which a patient receives more than one prescription qualify for application of E/M Level of 99284, even if that is the only service provided to that patient during the ED visit. ACEP instructs coders that “The facility code level assigned is always the highest level at which a minimum of one “Possible Intervention” is found.” 


  1. “Wound recheck”, “suture removal” or “prescription refill, only, asymptomatic” qualify for application of E/M code 99281, but policy should be written that addresses patients who were not initially treated for the initial wound or laceration repair in your ED. Does resource utilization in this scenario still qualify for code 99281? 


  1. A policy or guideline that defines “prescription” medications for ibuprofen should be considered and should define ibuprofen 200 mg as a prescription or an over-the-counter medication. Similarly, 800 mg of ibuprofen should also be defined as a prescription (99283) or an over-the-counter medication (99282). 


  1. Policy defining “mental health, anxious – simple treatment” or “routine psych medical clearance” (99283) should address whether a simple treatment includes a PO medication or a medical clearance followed by clearance by a psychiatric evaluator. Or does it simply require a medical clearance by an ED physician?


  1. In the ACEP criteria, “Administration and monitoring of infusions or parenteral medications (i.e., IV, IM, IO, SC) is documented as qualifying for E/M Level 99284. Policy should be written that addresses the types and numbers of infusions and medications. For example, does the patient who receives one IM injection of Benadryl use the same resources as the one who is given IM Robaxin, IV Ativan, IV Zofran, and IV Toradol? Similarly, does a patient who receives 5 different lab studies, IM Robaxin, IV Ativan, IV Zofran, and 3,000 ccs of IV Normal Saline require the same resources as the patient who received one IM injection of Benadryl?


  1. In the ACEP criteria, under E/M level 99285, how is “Preparation for > 3 diagnostic tests interpreted by your coders? Does 3 diagnostic tests include a CBC, a CMP, and a UA? Or must “3 diagnostic tests” include at least one from each of the following – EKG, Lab, and X-ray?” BSA has performed audits in which coders from the same hospital interpreted this statement differently, because there was no guideline that addressed this.


Additionally, how do your coders define “Prep for special imaging study (CT, MRI, Ultrasound, VQ scan) combined with multiple tests or parenteral medication or oral or IV contrast?” How are multiple tests defined by your coders? Is “multiple tests” defined as a CBC and a BMP in addition to a special study, or does it require one or more labs and an EKG or X-rays?


As stated previously, one of the eleven guiding principles is that criteria “Be applied consistently across patients in the emergency department to which they apply.” While there is more consistency among coders who use the ACEP criteria, BSA Healthcare has performed audits that revealed prevalent inconsistencies with new coders, as well as coders who work for institutions that have not defined issues that arise as a result of using the ACEP criteria without internal, written policies and guidelines. BSA strongly recommends that facilities using the ACEP criteria construct and implement written guidelines that apply rules to gray areas in the ACEP criteria.


BSA Healthcare regularly performs facility coding compliance audits. Our team can help your organization determine whether coders use the ACEP criteria or your unique facility criteria consistently and accurately. In performing facility coding audits for your organization, BSA Healthcare can help you to:


  • Audit records to determine whether coders correctly follow your facility criteria.

  • Determine whether your emergency department criteria is in keeping with CMS’ eleven principals for development of facility criteria.

  • Help write new policy, or revise current policy.

  • Educate your coders on proper use of facility criteria.

  • Determine whether your criteria appropriately reflects resources used in caring for emergency department patients, thereby reducing the risk of over- or underpayment.

  • Ensure correct utilization of infusion, injection, surgical, and medical codes that accurately reflect services performed in our nation’s EDs.