{"id":804,"date":"2023-04-26T10:20:58","date_gmt":"2023-04-26T14:20:58","guid":{"rendered":"https:\/\/blogs.duanemorris.com\/healthlaw\/?p=804"},"modified":"2023-04-26T10:25:49","modified_gmt":"2023-04-26T14:25:49","slug":"cms-rules-for-coding-emergency-department-claims","status":"publish","type":"post","link":"https:\/\/blogs.duanemorris.com\/healthlaw\/2023\/04\/26\/cms-rules-for-coding-emergency-department-claims\/","title":{"rendered":"CMS Rules for Coding Emergency Department Claims"},"content":{"rendered":"

By Gregory A. Brodek<\/a> and Arti Fotedar<\/a><\/strong><\/em><\/p>\n

The Centers for Medicare and Medicaid Services (CMS) has consistently authorized hospitals to establish and utilize their own coding guidelines for emergency department facility claims. CMS makes clear that \u201c[a]s long as the services furnished are documented and medically necessary and the facility is following its own system, which reasonably relates the intensity of hospital resources to the different levels of HCPCS codes, we will assume that it is in compliance with these reporting requirements as they relate to the clinic\/ emergency department visit code reported on the bill.\u201d 65 Fed. Reg. 18433, 18451 (Apr. 7, 2000)<\/a>. CMS also makes clear that \u201c[t]he coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply\u201d and should be verifiable by hospital staff and outside sources. 72 Fed. Reg. 66759, 66805 (Nov. 27, 2007)<\/a>. <\/p>\n

Hospitals should be mindful of payer policies which may contradict or ignore the above CMS rules. Highmark Inc. (Highmark), for example, recently issued a Special Bulletin<\/a> (Bulletin) on emergency department services for facility providers. The Bulletin states that beginning on May 1, 2023, \u201cHighmark will review the diagnoses submitted as well as the services performed to determine the appropriate level of care for the visit….\u201d The Bulletin also provides that Highmark\u2019s audits \u201cmay result in a different reimbursement than expected\u201d and that Highmark would update \u201cthe procedure codes [the facility] listed on the claim to the correct procedure code.\u201d Highmark further indicates that if a provider disagrees with Highmark\u2019s assigned level of care for a claim, the provider can file an appeal and submit related medical records. Highmark\u2019s Reimbursement Policy RP-037: Emergency Evaluation and Management Coding Guidelines<\/a> provides a full description of the changes.<\/p>\n

Facility providers should evaluate whether a payer\u2019s policy violates their contractual rights, and take such steps as they deem appropriate, including reaching out to appropriate payer representatives and considering what rights the provider may have to prevent implementation of the policy.<\/p>\n","protected":false},"excerpt":{"rendered":"

By Gregory A. Brodek and Arti Fotedar The Centers for Medicare and Medicaid Services (CMS) has consistently authorized hospitals to establish and utilize their own coding guidelines for emergency department facility claims. CMS makes clear that \u201c[a]s long as the services furnished are documented and medically necessary and the facility is following its own system, … <\/p>\n

Continue reading “CMS Rules for Coding Emergency Department Claims”<\/span><\/a><\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5],"tags":[983,380,318,319,662,9,10],"ppma_author":[906],"class_list":["post-804","post","type-post","status-publish","format-standard","hentry","category-health-law","tag-arti-fotedar","tag-centers-for-medicare-and-medicaid-services","tag-coding","tag-emergency-department","tag-greg-brodek","tag-medicaid","tag-medicare"],"authors":[{"term_id":906,"user_id":6,"is_guest":0,"slug":"duanemorris3","display_name":"Duane Morris","avatar_url":"https:\/\/secure.gravatar.com\/avatar\/843ff6e7a8fe5fc92109b47a45f34b6cf0ea499e6e788db23456c838b0ae6747?s=96&d=blank&r=g","0":null,"1":"","2":"","3":"","4":"","5":"","6":"","7":"","8":""}],"_links":{"self":[{"href":"https:\/\/blogs.duanemorris.com\/healthlaw\/wp-json\/wp\/v2\/posts\/804","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.duanemorris.com\/healthlaw\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.duanemorris.com\/healthlaw\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.duanemorris.com\/healthlaw\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.duanemorris.com\/healthlaw\/wp-json\/wp\/v2\/comments?post=804"}],"version-history":[{"count":0,"href":"https:\/\/blogs.duanemorris.com\/healthlaw\/wp-json\/wp\/v2\/posts\/804\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.duanemorris.com\/healthlaw\/wp-json\/wp\/v2\/media?parent=804"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.duanemorris.com\/healthlaw\/wp-json\/wp\/v2\/categories?post=804"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.duanemorris.com\/healthlaw\/wp-json\/wp\/v2\/tags?post=804"},{"taxonomy":"author","embeddable":true,"href":"https:\/\/blogs.duanemorris.com\/healthlaw\/wp-json\/wp\/v2\/ppma_author?post=804"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}