Emergency Room


From implementation of the Outpatient Prospective payment system OPPS, the CMS has requested hospitals to report facility resources for emergency department ED visit using CPT evaluation and management E/M codes. However, CMS recognized that CPT E/M codes do not adequately describe the intensity and range of ED services by hospitals because they reflect physician activities. Therefore, CMS instructed hospitals to develop their own internal guidelines for reporting E/M visits


Two of the best-known models for ED visit levels are the AHA/AHIMA Guidelines and the American College of Emergency Physicians ED Facility Level Coding Guidelines (ACEP Guidelines). During its consideration of various available guidelines, CMS identified four basic models in use

  1. Guidelines based on the number or type of staff interventions (AHIMA & ACEP)
  2. Guidelines based on time spent with the patient. As time spent with the patient increases, so does the level assigned
  3. Guidelines based on a point system. The time, complexity, and type of staff required determine the number of points assigned to each intervention
  4. Guidelines based on patient severity. The diagnoses, level of medical decision making, and presenting complaint or medical problem are used to correlate resource consumption.

ED hospital Guidelines:

CMS makes clear that hospital guidelines must reasonably relate to the intensity of hospital resources to the levels of effort represented by the codes

Ø  Follow the intent of the CPT code descriptor—the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code   

Ø  Be based on hospital facility resources, not physician resources    

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

Ø  Meet HIPAA requirements

Ø  Require only documentation that is clinically necessary for patient care

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

Ø  Be applied consistently across patients in the clinic or emergency department to which they apply

Separately Payable Procedures:

Ø  In its evaluation of the available models, CMS found some systems too complex and over burdensome, susceptible to variability, and subjective in interpretation of guidelines. It also found that all proposed guidelines allow for counting of separately paid services (e.g., intravenous infusion, x-ray, EKG, and lab tests) as interventions or staff time in determining a level of service

Ø  In the 2008 OPPS final rule, CMS stated that, 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.”3 Hospitals must be able to substantiate any decision to include otherwise separately payable services as a determining factor in the ED level assignment and be able to clearly articulate why those services reflect a proxy for additional hospital resource consumption.

Reporting Modifiers:

Hospitals have increased their internal monitoring of modifier -25 because of the Office of Inspector General’s emphasis on correct -25 assignments and increased activity by the Department of Justice to review hospital billing practices related to the modifier’s use

To append modifier -25 appropriately to an E/M code, the service provided must meet the definition of a “significant, separately identifiable E/M service” as defined by CPT. It is appropriate to append modifier -25 to ED codes when these services lead to a decision to perform diagnostic or therapeutic procedures.

ACUITY Caveation Rule:

ED visit for the evaluation and management of a patient, which requires these three key components (History, Exam, MDM) within the constraints imposed by the urgency of the patient imposed patient s’ clinical condition and/or mental status

THE “EMERGENCY MEDICINE” CAVEAT “If the physician is unable to obtain a history from the patient or other source, provider can caveat the History. However, the record should describe the patient’s condition or other circumstances which precludes obtaining a history.” E.g. Patient with dementia, Severe dyspnoea (CHF or Asthma)