Navigating ED ProFee Coding vs Facility Coding: A Comprehensive Guide

Highcare RCM

In the Emergency Department (ED) coding and billing, the healthcare providers encounter two distinct methodologies: Professional Fee Coding and Facility Coding. Within the Emergency Department setting, there are five distinct levels of emergency services, represented by CPT codes 99281 – 99285. The main difference is, professional coding is mandated by CMS and Facility coding is specific to each facility. In this article, we will delve into the nuances of both coding systems, particularly in the ED setting, highlighting the key differences and guidelines that ensure accurate billing and coding practices.

ProFee Coding:

Professional Fee Coding centers on the services provided by healthcare professionals within the Emergency Department. The complexity and intensity of the provider’s work, including cognitive effort, are considered when selecting the appropriate level of professional services. The primary determinant for these codes is the Medical Decision Making (MDM), provided by the American Medical Association (AMA) (as per the 2023 E&M code and guideline changes).

No distinction is made between new and established patients in the emergency department. Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.

Payment for professional fee services is based on the Relative Value Unit (RVU) methodology assigned to each CPT code. The Physician Fee Schedule (PFS) allows separate payment for each CPT/HCPCS code reported on a claim, as long as medical necessity and other payor-specific guidelines have been met for the reported service.

For billing purposes, ProFee coding employs the CMS-1500 form, which is used to bill Medicare Fee-For-Service (FFS) Contractors for services provided by physicians and other qualified health care professionals.

Facility Coding:

Facility Coding, on the other hand, reflects the volume and intensity of resources utilized by the facility during patient care in the ED. CMS acknowledges that the level of Evaluation and Management (E/M) services reported by the hospital may not always align with the level reported by the physician for their professional services during the same patient encounter. As a result, CMS advises facilities to code the E/M level based on the resources utilized by the facility rather than the resources used by the physician. This includes situations where patients may see a physician only briefly, or not at all. To facilitate accurate reporting, CMS encourages hospitals to establish their own internal guidelines for reporting E/M visits.

CMS identified four (4) basic models in use when determining facility levels,

Number or type of staff interventions:

Intervention models use basic care interventions to report the lowest level of service, with higher levels assigned as complexity or number of nursing and ancillary staff interventions increases.

AHA/AHIMA Guidelines and the ACEP Guidelines fall into this category.

Time:

The level of service increases with the time spent with the patient.

Point system:

Partnering with such experts Points are assigned based on time, complexity, and type of staff required for each intervention.

Patient Severity:

The diagnoses, level of medical decision making, and presenting complaint or medical problem are used to correlate resource consumption.

Two of the most commonly used models are AHA/AHIMA Guidelines and the American College of Emergency Physicians ED Facility Level Coding Guidelines (ACEP Guidelines).

While the healthcare industry continues to operate without national guidelines, CMS expects that each hospital’s internal guidelines should:

  • 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
  • Be based on hospital facility resources, not physician resources
  • Be clear to facilitate accurate payments and be usable for compliance purposes and audits
  • Meet HIPAA requirements
  • Require only 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 clinic or emergency department to which they apply
  • Not change with great frequency
  • Be readily available for fiscal intermediary (or, if applicable, MAC) review
  • Result in coding decisions that could be verified by other hospital staff, as well as outside resources

APCs (Ambulatory Payment Classifications) are an outpatient prospective payment system applicable only to hospitals. They have no impact on physician payments under the Medicare Physician Fee Schedule.

For billing purposes, facility coding uses the UB-04 form, specifically designed for billing insurances and Medicare for services provided by hospitals.

Modifiers Usage in both ProFee and Facility Coding

Modifiers play a crucial role in both ED ProFee Coding and Facility Coding, helping to provide additional information and context to ensure accurate billing and reimbursement. In the ProFee Coding setting, commonly used modifiers include 25 and GC. Modifier 25 is used when an Evaluation and Management (E/M) service is performed on the same day as another procedure, indicating that the E/M service was separately identifiable and significant. Modifier GC is used to signify that the Service has been performed in Part by a Resident under the Direction of a Teaching Physician.

On the other hand, Facility Coding employs modifiers such as 50, 52, and 59. Modifier 50 is used when a procedure is performed bilaterally, while Modifier 52 indicates that a procedure was partially reduced or discontinued. Modifier 59 is utilized to identify distinct procedural services that are not typically bundled together.

In both coding methodologies, the proper use of modifiers is essential to avoid claim denials, ensure compliance, and reflect the true complexity of the services rendered. Healthcare providers must understand the specific guidelines and requirements associated with each modifier to accurately apply them in their coding practices.

Understanding the differences between ED ProFee Coding and Facility Coding is crucial for accurate billing and efficient reimbursement in the Emergency Department setting. While ProFee Coding centers on the complexity and intensity of the provider’s work, Facility Coding focuses on the resources utilized by the facility during patient care. Each approach has its unique guidelines and requirements.

Our experts at High Care RCM Services have a deep understanding of ProFee and Facility Coding requirements, ensure that the accurately reflects the efforts and resources of healthcare providers.

Together, we can achieve optimal reimbursement, compliance, and patient satisfaction, making a positive impact on your facility’s financial health and overall success. Contact us today to learn more about our comprehensive RCM solutions tailored to your specific needs.

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