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 “[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.” 65 Fed. Reg. 18433, 18451 (Apr. 7, 2000). CMS also makes clear that “[t]he coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply” and should be verifiable by hospital staff and outside sources. 72 Fed. Reg. 66759, 66805 (Nov. 27, 2007).
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 (Bulletin) on emergency department services for facility providers. The Bulletin states that beginning on May 1, 2023, “Highmark will review the diagnoses submitted as well as the services performed to determine the appropriate level of care for the visit….” The Bulletin also provides that Highmark’s audits “may result in a different reimbursement than expected” and that Highmark would update “the procedure codes [the facility] listed on the claim to the correct procedure code.” Highmark further indicates that if a provider disagrees with Highmark’s assigned level of care for a claim, the provider can file an appeal and submit related medical records. Highmark’s Reimbursement Policy RP-037: Emergency Evaluation and Management Coding Guidelines provides a full description of the changes.
Facility providers should evaluate whether a payer’s 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.