ED Facility Level Coding Guidelines

Introduction

A part of the Federal Balanced Budget Act of 1997 required HCFA (now CMS) to create a new
Medicare "Outpatient Prospective Payment System" (OPPS) for hospital outpatient services;
analogous to the Medicare prospective payment system for hospital inpatients known as "Diagnosis
Related Groups" or DRG's. APC's or "Ambulatory Payment Classifications" are the government's
method of paying for facility outpatient services for the Medicare program. APC's apply only to
hospitals, and have no impact on physician payments under the Medicare Physician Fee Schedule.
For further information about APC's, see the Frequently Asked Questions on the ACEP website.

Facility coding guidelines are inherently different from professional coding guidelines. Facility coding
reflects the volume and intensity of resources utilized by the facility to provide patient care, whereas
professional codes are determined based on the complexity and intensity of provider performed
work and include the cognitive effort expended by the provider. As such, there is no definitive strong
correlation between facility and professional coding and thus no rational basis for the application of
one set of derived codes, either facility or professional, to the determination of the other on a case-
by-case basis.

In 2011 OPPS, CMS restated its position on "Triage-only" visits confirming that it does not specify the
type of staff who may provide services. "A hospital may bill a visit code based on the hospital's own
coding guidelines which must reasonably relate the intensity of hospital resources to different levels
of HCPCS codes. Services furnished must be medically necessary and documented."

However, in a 2012 Facility FAQ, CMS indicated that Hospital outpatient therapeutic services and
supplies (including visits) must be furnished incident to a physician's service and under the order of
a physician or other qualified practitioner. Services provided by a nurse in response to a standing
order do not satisfy this requirement. Since diagnostic services do not need to meet the
requirements for incident to services, they may be coded even if the patient were to leave without
being seen by the physician.

At this point, there is no national standard for hospital assignment of E&M code levels for outpatient
services in clinics and the Emergency Department (ED). CMS requires each hospital to establish its
own facility billing guidelines. Further, OPPS lists eleven criteria that must be met for facility billing
guidelines. (see APC FAQ) Facility billing guidelines should be designed to reasonably relate the
intensity of hospital services to the different levels of effort represented by the codes. Coding
guidelines should be based on facility resources, should be clear to facilitate accurate payments,
should only require documentation that is clinically necessary for patient care, and should not
facilitate upcoding or gaming. For further information, see the 2009 CMS Final Rule for facility
billing. A summary of the OPPS rule is available on the ACEP website.

ACEP believes the facility billing guidelines outlined below are consistent with the OPPS principles
and provides them as one possible set of guidelines. Facilities using the guidelines should ensure
they are appropriate for use and reflect the salient circumstances of their institution. Some facilities
have found it helpful to adapt the guidelines to the particular needs of their institution.

Instructions for Use

The ACEP facility coding model provides an easy to use methodology for assigning visit levels in an
Emergency Department (ED). There are three columns in the guidelines. The far left column indicates
the facility codes and corresponding APC levels which are justified by the "Possible Interventions"
listed in the middle column. The far right column labeled "Potential Symptoms/Examples which
Support the Interventions" is simply used as an aid to the coder in determining which interventions
most likely correspond with a given facility code/APC level. This far right column of "Potential
Symptoms/Examples" is not used to determine the appropriate facility code/APC level. The
determination of the appropriate facility code/APC level is based solely on the "Possible
Interventions" listed in the middle column. The "Possible Interventions" refer to interventions on
the part of the nursing and ancillary staff in the Emergency Department and not to interventions by
the emergency physicians. “Possible Interventions" includes some procedure examples which might
be billed separately by the facility. The procedures listed serve as a proxy, qualifying the typical
intensity of facility services provided for patients requiring them. Such procedure examples are not
intended to substitute for or duplicate labor, time or supplies included in separately billable
procedures. Levels of "Discharge Instructions" are defined in the last section of these guidelines.

The appropriate facility code/APC level is determined by the interventions (of nursing and ancillary
ED staff) as listed in the middle column marked "Possible Interventions". If a given "Possible
Intervention" is listed in a section assigned to a specific facility code level, and if no other
interventions are provided that fall into a higher facility code level, then the facility code level
corresponding to that specific "Possible Intervention" is selected as the appropriate "facility
code/APC level". Within a given facility code/APC level, there may be multiple "Possible
Interventions" provided, all of which fall into the same facility code/APC level. Whether there is a
single "Possible Intervention" or multiple "Possible Interventions"-all of which fall into the same
facility code/APC level-the appropriate facility code/APC level to be assigned remains the same. In
other words, whether only a single "Possible Intervention" listed at a given facility code level is
present or if multiple or all "Possible Interventions" assigned to that facility code level are present-
the facility code/APC level is still the same.

In the "Possible Interventions" column, the first sentence states, "Could include interventions from
previous (lower) levels, plus any of:" This simply means, for example, that if the highest facility
code/APC level achieved by any "Possible Intervention" is a facility code 99283 and APC level 614,
then the appropriate facility code to assign is a 99283. The presence of "Possible Interventions" from
levels 99281 and/or 99282 in addition to the "Possible Intervention" listed in the 99283 section has
no effect on the facility code level assigned. The facility code level assigned is always the highest
level at which a minimum of one "Possible Intervention" is found.

An example of correct usage of this "Guideline" follows:

Example # 1

A 48 year old woman with a prior history of a myocardial infarction and atrial fibrillation comes to
the emergency department complaining of pelvic pain. She receives an initial assessment by the ED
nurse; she also has tests performed by the ED staff consisting of a stool hemoccult test and a urine
dipstick test. She has a saline lock inserted by the ED nurse and subsequently has blood drawn
through that IV site, and blood is sent to the Laboratory for several tests. The urine specimen was
obtained following the insertion of a Foley catheter by the ED nurse. The patient is examined by the
ED physician, including the performance of a pelvic examination (the ED nurse is in attendance
during the pelvic exam). The patient is also prepared and sent to Radiology for the performance of a
pelvic ultrasound examination. Transport to the Radiology Department is provided by Emergency
Department staff, and the patient is monitored (cardiac monitor) during transport and the
accomplishment of the pelvic ultrasound. Following the return of all tests, the ED physician
diagnoses the patient with a ruptured ovarian cyst, prescribes analgesics, instructs the patient to
follow-up the following day with her OB-GYN specialist, and instructs her to rest at home for the next
48 hours. The nurse provides discharge instructions which are "Complex" (See definitions for levels of
nursing instructions in the last section of these guidelines). The coder then uses the "Guidelines" as
follows: First the coder looks in the far right hand column for "Pelvic Pain". This symptom is not
listed; however "Abdominal Pain" is listed at both the 99284 and 99285 levels. Therefore, the coder
looks at the 99285 level for any "Possible Intervention" provided by the nursing and ancillary ED staff
at the 99285 level. Under the 99285 level of "Possible Interventions" are two of the interventions
provided to this patient:

A. Monitoring vital signs of patient during in-hospital transport and testing

The appropriate level of "Facility code" for services provided to this ED patient is therefore 99285
and the corresponding appropriate APC level is 616.

Example #2

A 66 year old woman who has been in excellent health and who takes no prescription medications
comes to the Emergency Department complaining of low grade fever, dysuria and urinary frequency.
The ED nurse assesses her and performs a urine dipstick examination on a urine specimen obtained
by an "in and out" Foley catheterization-on the order of the ED physician. The ED physician examines
the patient, the only positive findings are a temperature of 101 degrees Fahrenheit (oral) and
moderate suprapubic tenderness. The urine dipstick examination is positive for leukocyte esterase
and for nitrites but is otherwise negative. The physician diagnoses "Acute Cystitis" and prescribes
antibiotics and analgesics. The nurse gives the patient one tablet of Pyridium and one tablet of
Sulfamethoxazole/Trimethoprim which the patient takes while in the ED. The ED nurse provides
discharge instructions of "Moderate Complexity". The patient returns home.

The coder looks in the far right column under "Potential Symptoms/Examples" and finds two items
applicable to this patient:

A. Medical conditions requiring prescription drug management

The coder thus looks for "Possible Interventions at the 99283 level-which corresponds to the
"Potential Symptoms/Examples" which are present in regard to this patient. The coder finds the
following interventions which were provided to this patient:

A. Prescription medications administered PO

The coder then looks at facility code levels 99284 and 99285 to determine if any interventions falling
within those levels were provided. The coder determines that the highest facility code level achieved
by any intervention provided to this patient is intervention at the 99283 level. Thus, the coder
assigns facility code 99283 (APC 614) as the appropriate "Facility Code Level".

Critical Care
Facility code 99291 - APC Level 617

The assignment of the Critical Care code 99291 likewise follows the same instructions applicable to
the five E&M codes 99281-99285. There is a 30 minute time requirement for facility billing of critical
care.
The administration and monitoring of IV vasoactive medications (such as adenosine, dopamine,
labetolol, metoprolol, nitroglycerin, norepinephrine, sodium nitroprusside, etc) is indicative of critical
care.

Example:

EMS brings in a 68 year old man who is suffering grand mal convulsions, with only brief interludes of
from one to three minutes between convulsions. He undergoes a multiplicity of diagnostic tests,
receives 2 mg of Ativan IV followed by an IV infusion of one gram of Dilantin over one hour. His blood
pressure is 240/140 and he receives an IV infusion of sodium nitroprusside which brings his pressure
down to180/110. A C-T scan reveals an acute intracerebral hemorrhage which is fairly small and
which has not yet resulted in any mid-line shift of the cerebral hemispheres. He is transferred to
another hospital (to the on-call neurosurgeon) for numerous reasons, including the family's wishes
and the fact that the only neurosurgeon in town is presently in surgery at the "other hospital". 45
minutes of Critical Care is documented.

The coder looks under "Potential Symptoms/Examples" and finds "Status-Asthmaticus, Epilepticus"
as well as "Cerebral Hemorrhage of any type" listed under the "Critical Care" section. The coder
identifies documentation that the patient received IV drips of Dilantin and sodium nitroprusside and
then finds the intervention of "Multiple parenteral medications requiring constant monitoring" under
the "Critical Care" guideline. With 45 minutes of Critical Care time documented and since only a
single intervention listed under the "Possible Interventions" applicable to "Critical care" is necessary
in order to assign facility code 99291, the coder assigns Critical Care code 99291 (APC 617).

Definitions for Discharge Instructions

Straightforward: Self-limited condition with no meds or home treatment required, signs and
symptoms of wound infection explained, return to ED if problems develop

Simple: OTC medications or treatment, simple dressing changes; patient demonstrates

Moderate: Head injury instructions, crutch training, bending, lifting, weight-bearing limitations,
prescription medication with review of side effects and potential adverse reactions; patient may have
questions, but otherwise demonstrates adequate understanding of instructions either verbally or by
demonstration

Complex: Multiple prescription medications and/or home therapies with review of side effects and
potential adverse reactions; diabetic, seizure or asthma teaching in compromised or non-compliant
patients; patient/caregiver may demonstrate difficulty understanding instructions and may require
additional directions to support compliance with prescribed treatment.

Disclaimer

The American College of Emergency Physicians (ACEP) has developed these ED Facility Level Coding
Guidelines (Guidelines) for informational purposes only. These Guidelines have been developed by
sources believed to be knowledgeable in their fields and conveys their editorial opinion behind the
various codes. However, neither ACEP nor its committee members, authors or editors warrant that
the information contained in the Guidelines is in every respect accurate and/or complete. ACEP, its
committee members, authors and editors assume no responsibility for, and expressly disclaim
liability for, damages of any kind arising out of or relating to the use of, reference to, or reliance on
 the Guidelines. These Guidelines are not intended to be construed or to serve as the definitive
reference for CMS OPPS coding. OPPS coding is determined on the basis of all the facts and
circumstances involved in each individual case and is subject to change as patterns of practice
evolve. Payment policies for OPPS are determined by CMS. Therefore, any specific payment related
questions or issues must be directed to CMS.

Facility Charge Assignment

Level Possible Interventions1 Potential Symptoms/Examples which support the Interventi

I Initial Assessment Insect bite (uncomplicated)

II Could include interventions from previous levels, plus Localized skin rash, lesion, sunburn
CPT 99282 Type any of: Minor viral infection
A: APC 613Type Tests by ED Staff (Urine dip, stool hemoccult, Eye discharge- painless
B: APC Accucheck or Dextrostix) Ear Pain
627HCPCS: Visual Acuity (Snellen) Urinary frequency without fever
G0381 Obtain clean catch urine Simple trauma (with no X-rays)
Apply ace wrap or sling
Prep or assist w/ procedures such as: minor
laceration repair, I&D of simple abscess, etc.
Discussion of Discharge Instructions (Simple)

III Could include interventions from previous levels, plus Minor trauma (with potential complicating factors)
CPT 99283 Type any of: Medical conditions requiring prescription drug management
A: APC 614Type Receipt of EMS/Ambulance patient Fever which responds to antipyretics
Headache - Hx of, no serial exam
B: APC Heparin/saline lock
Head injury- without neurologic symptoms
628HCPCS: (1) Nebulizer treatment
Eye pain
G0382 Preparation for lab tests described in CPT (80048- Mild dyspnea -not requiring oxygen
87999 codes)Preparation for EKG
Preparation for plain X-rays of only 1 area (hand,
shoulder, pelvis, etc.)
Prescription medications administered PO
Foley catheters; In & Out caths
C-Spine precautions
Fluorescein stain
Emesis/ Incontinence care
Prep or assist w/procedures such as: joint
aspiration/injection, simple fracture care etc.
Mental Health-anxious, simple treatment
 Routine psych medical clearance
Limited social worker intervention
Post mortem care
Direct Admit via ED
Discussion of Discharge Instructions (Moderate
Complexity)

IV Could include interventions from previous levels, plus Blunt/ penetrating trauma- with limited diagnostic testing
CPT 99284 Type any of: Headache with nausea/ vomiting
A: APC 615Type Preparation for 2 diagnostic tests2: (Labs, EKG, X-ray) Dehydration requiring treatment
B: APC Prep for plain X-ray (multiple body areas): Vomiting requiring treatment
629HCPCS: C-spine & foot, shoulder & pelvis Dyspnea requiring oxygen
G0383 Prep for special imaging study (CT, MRI, Respiratory illness relieved with (2) nebulizer treatments
Ultrasound,VQ scans) Chest Pain--with limited diagnostic testing
Cardiac Monitoring (2) Nebulizer treatments Abdominal Pain - with limited diagnostic testing
Port-a-cath venous access Non-menstrual vaginal bleeding
Administration and Monitoring of infusions or Neurologic symptoms - with limited diagnostic testing
parenteral medications (IV, IM, IO, SC) NG/PEG
Tube Placement/Replacement Multiple
reassessments
Prep or assist w/procedures such as: eye irrigation
with Morgan lens, bladder irrigation with 3-way foley,
pelvic exam, etc.
Sexual Assault Exam w/ out specimen collection
Psychotic patient; not suicidal
Discussion of Discharge Instructions (Complex)

V Could include interventions from previous levels, plus Blunt/ penetrating trauma requiring multiple diagnostic tests
Systemic multi-system medical emergency requiring multiple diagnostics
CPT 99285 Type any of:
Severe infections requiring IV/IM antibiotics
A: APC 616Type Requires frequent monitoring of multiple vital signs Uncontrolled DM
B: APC (ie. 02 sat, BP, cardiac rhythm, respiratory rate) Severe burns
630 HCPCS: Preparation for ≥ 3 diagnostic tests2: (Labs, EKG, X- Hypothermia
G0384 ray) New-onset altered mental status
Headache (severe): CT and/or LP
Prep for special imaging study (CT, MRI, Ultrasound,
Chest Pain--multiple diagnostic tests/treatments
VQ scan) combined with multiple tests or parenteral Respiratory illness--relieved by (3) or more nebulizer treatments
medication or oral or IV contrast. Abdominal Pain--multiple diagnostic tests/treatments
Administration of Blood Transfusion/Blood Products Major musculoskeletal injury
Acute peripheral vascular compromise of extremities
Oxygen via face mask or NRB Multiple Nebulizer
Neurologic symptoms - multiple diagnostic tests/treatments
Treatments: (3) or more (if nebulizer is continuous, Toxic ingestions Mental health problem - suicidal/ homicidal
each 20 minute period is considered treatment)
Moderate Sedation
Prep or assist with procedures such as: central line
insertion, gastric lavage, LP, paracentesis,etc.
Cooling or heating blanket
Extended Social Worker intervention
Sexual Assault Exam w/ specimen collection by ED
staff
Coordination of hospital admission/ transfer or
 change in living situation or site
Physical/Chemical Restraints;
Suicide Watch
Critical Care less than 30 minutes

Critical Care - Critical Care can be coded based upon either the provision of any of the listed possible interventions or by satisfying the Critical Care definition. A minimum of 30 minutes
care must be provided. Critical Care Involves decision-making of high complexity to assess, manipulate, and support impairments of "one or more vital organ systems such that there is
probability of imminent or life threatening deterioration in the patient's condition." This includes, but is not limited to, "the treatment or prevention of further deterioration of central n
system failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, post-operative complications or overwhelming infection." Under OPPS, the time that can be reporte
Critical Care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff
multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once.

Possible Interventions Potential Symptoms/Examples which support the Interventi

CPT 99291 Could include interventions from previous levels, plus Multiple Trauma; Head Injury with loss of consciousness
Burns threatening to life or limb
Type A: APC 617 any or all of:
Coma of all etiologies (except hypoglycemic)
Multiple parenteral medications requiring constant Shock of all types: septic, cardiogenic, spinal, hypovolemic, anaphylactic
monitoring Drug Overdose impairing vital functions
Provision of any of the following: Life-threatening hyper/ hypo-thermia
Major Trauma care/ multiple surgical consultants Thyroid Storm or Addisonian Crisis
Cerebral hemorrhage of any type
Chest tube insertion
New-onset paralysis
Major burn care Non-hemorrhagic strokes with vital function impairment
Treatment of active chest pain in ACS Status epilepticus
Administration of IV vasoactive meds (see guidelines) Acute Myocardial Infarction
Cardiac Arrythmia requiring emergency treatment
CPR
Aortic Dissection
Defibrillation/ Cardioversion Cardiac Tamponade
Pericardiocentesis Aneurysm; thoracic or abdominal -- leaking or ruptured
Administration of ACLS Drugs in cardiac arrest Tension Pneumothorax
Therapeutic hypothermia Acute respiratory failure, pulmonary edema, status asthmaticus
Pulmonary Embolus
Bi-PAP/ CPAP
Embolus of fat or amniotic fluid
Endotracheal intubation Acute renal failure
Cricothyrotomy Acute hepatic failure
Ventilator management Diabetic Ketoacidosis
Lactic Acidosis
Arterial line placement
DIC or other bleeding diatheses - hemophilia, ITP, TTP, leukemia, aplastic a
Control of major hemorrhage Major Envenomation by poisonous reptiles
Pacemaker insertion through a Central Line
Delivery of baby

CPT 99292 As above in additional 30 minute increments. Record the TOTAL critical care time. The first 30-74 minutes equal code 99291. If used, additional 30 minute incre
(beyond the first 74 minutes) are coded 99292. Medicare does not pay for code 99292 because it is considered packaged into 99291; however the services sho
reported as appropriate.

Critical Care with In addition to 99291, designated trauma centers may report the Trauma Team Activation code G0390 when a trauma team was activated and all other trauma
activation criteria are met.
Trauma Team
ActivationAPC
618G0390

Copyright © 2011 American College of Emergency Physicians

If you intend to use these guidelines, or an adaptation of them, Copyright permission can be
requested here.
If you have questions please contact the ACEP Reimbursement Department at 1-800-798-1822.

Footnote 1: Hospital outpatient therapeutic services and supplies (including visits) must be
furnished incident to a physician's service and under the order of a physician or other qualified
practitioner. Services provided by a nurse in response to a standing order do not satisfy this
requirement. Since Diagnostic tests do not have to be performed incident to a physician service,
they may be coded even if the patient were to leave without being seen by the physician.

Footnote 2: As of 2021, CPT has clarified that a test is defined as a service that has a separate CPT
code. Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg,
basic metabolic panel [80047]) is a single test. The differentiation between single or multiple unique
tests is defined in accordance with the CPT code set.