A hospital must assign Emergency Room Evaluation and Management codes (E/M) codes for all ER visits.  The E/M code is billed in Revenue Code 450 –Emergency Room on the UB-04.


Below are a few of the common issues encountered when we review Emergency Room records:

1. ER criteria is not applied correctly and incorrect E/M level are assigned, resulting in over coding or under coding.

2. Incorrect points assigned and therefore incorrect code is billed; many facilities use a point system to assign levels of care based on services rendered.

3. Documentation does not substantiate the E/M level assigned.

4. Criteria outlines that a level 5 visit (99285) is automatically assigned if patient admitted to the hospital or transferred even if services provided do not justify a level 5.

All facilities should have an ER matrix, ER criteria or ER acuity sheet that is used to determine the E/M level assigned for each visit rendered in the ER. The ER matrix/criteria/acuity sheet must be applied consistently to all hospital visits.  


Suggestions for applying ER matrix:

1. The person/staff who assigns the ER E/M levels must understand the criteria and services/documentation required to substantiate each level.

2. Require the ER Matrix be completed for each visit to substantiate the E/M level assigned.


Implement a review process to include:

1. Review process to determine if the matrix is applied properly to cases coded and the correct level is assigned; Pre-bill review is recommended.

2. Allow coder reviewing the record to question the E/M level assigned if the documentation does not substantiate the level assigned and follow the process in place to re-review or change the E/M level assigned based on documentation.

3. A formal process to change an assigned E/M based on the per-bill documentation review. This committee should involve practitioners as well as HIM and management.

4. Educate staff who assign the E/M levels if changes are made in the criteria and errors made in the assignment of levels.

It is important to have a process in place to make sure the criteria is accurately applied, the correct EM level is assigned and reviews are done to assure documentation substantiates the level.  This will assist in assuring you are receiving the proper payment and not under or over coding.


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