Emergency Department Coding Cheat Sheet
Delivering quality care while ensuring effective clinical documentation and compliant medical coding is an ongoing challenge in a fast paced emergency department ed.
Emergency department coding cheat sheet. Principles for emergency department coding guidelines. These services may be billed by any specialty physician not just emergency department physicians. In part 1 of this series we ll concentrate on. Since the implementation of the outpatient prospective payment system opps the centers for medicare and medicaid services cms has required hospitals to report facility resources for emergency department ed visits using cpt evaluation and management e m codes.
When the 1992 cpt e m code set for emergency medicine was developed patients received limited workups in the emergency department and were admitted as inpatients for their evaluations. As the practice of emergency medicine has changed and expanded over the years so has the complexity of coding for the various types of emergency department visits. Coding system icd 10 cm pcs 6. Emergency department codingemergency department coding.
Wilson is a senior emergency department auditor with healthcare coding and consulting services hccs. Emergency department coding handbook nena scott msed rhia ccs ccs p ccds ahima approved icd 10 cm pcs trainer this handbook is a quick reference guide for coders in emergency department ed settings. By tedi lojewski rhia ccs. It guides coders through assigning visit levels and documentation requirements for a variety of common ed services.
Patient type 6 setting of service 6 level of e m service performed 7 history7 elements required for each type of history 7 chief complaint cc 7 history of present illness hpi 8 review of systems ros 9. A pertinent pfs consists of any pfs consists of any 1 1 element from the pfselement from the pfs 99281 99281 99284 a ltpfs i t f 34 complete pfs consists of one element from element from 2 2 of the of the 3 3 pfs history pfs history. The physician does not need to be assigned to the ed. Emergency department ed services are e m services provided to patients in the emergency department.
The far left column indicates the facility codes and corresponding apc levels which are justified by the possible interventions listed in the middle column. Becky wilson ccs cpc ms. There are three columns in the guidelines. E m services providers 6 selecting the code that best represents the service furnished 6.