For the Emergency Department (ED) facility-level coding, CMS allows the hospitals to come up with their own coding methodology and does not provide any guidance on how to code the facility level. As a result, different organizations use different methodologies. Most commonly used methodologies are by American College of Emergency Physicians (ACEP) and American Health Information Management Association (AHIMA). ACEP and AHIMA have their own guidelines but their guidelines are more or less similar to regular E&M coding. Both these methodologies have factors that can be impacted by the judgement of the nursing and coding staff.
Some of the hospitals have opted to use what they call as “activity-based point scheme”. In this case, activities are based on the documentation which is done by the nursing staff and then coded separately by coders. At some places, nurses are doing documentation as well as coding based on documentation. However, the only issue with that is the compliance concern with “up-coding” since there is no separation between the staff doing documentation and coding and bias can easily set in without any check-and-balances.
Regardless of the methodology adopted, CMS guidelines state facilities should code a level of service based on facility resource consumption.
CTech’s solution brings a more comprehensive approach to coding and routine assessment of whether Medicare reimbursements are in line with resource utilization. Our approach and solution are being used at several hospital facilities and we believe it is a more objective, compliant and defendable coding methodology/practice using the hospital’s own (or outsourced coding) resources. In line with CMS guidelines that facilities should code a level of service based on facility resource consumption, salient aspects of our methodology are:
A number of other companies in this field try to use Standard Analytical Files (SAF) data to position the organization within a certain quartile in comparison to other facilities in the country. However, that in itself is not a sound approach. Our methodology will use SAF data just as another data point which can help us with overall decision-making process but placing or trying to force-fit the organization in a given quartile is not the objective. Our goal is to simply assist the facility to code a level of service based on facility resource consumption. To that effect, CTech has the following process in place:
With this approach, CTech believes the facility can use a consistent methodology that is compliant, dependable and the cost of services that are reimbursed through E&M levels are in line with the E&M revenue.