Introduction

Documentation in the emergency department (ED) medical record serves three basic functions:

Documentation in the ED chart must be both adequate to support reimbursement claims and accurate to prevent claims of billing fraud. What is not documented does not get reimbursed—in effect, it did not happen. Understanding the fundamentals of coding and billing from the ED chart is essential to ensure a revenue stream that supports the financial viability of the ED. This revenue is critical in enabling professional autonomy, continuing medical education, and improvements in ED patient care and technology. Revenue from patient care is obtained through two parallel billing structures: hospital billing and professional billing. This chapter focuses on professional billing.

Current Procedural Terminology Codes

Before publication of the Current Procedural Terminology (CPT) codes, third-party payers had their own idiosyncratic list of physician services and their respective codes, thus making consistent and reliable procedural billing extremely difficult. CPT coding was published by the American Medical Association (AMA) in 1966 in an attempt to standardize reimbursement for medical procedures. These codes are used to report physician services for claims processing and for local, regional, and national service utilization comparisons by the Centers for Medicare and Medicaid Services (CMS). CPT codes are reviewed annually by the AMA CPT Editorial Committee with input from various specialty physician organizations to account for new procedures and changes in reimbursement patterns.

A CPT code is a unique five-digit code that represents a service in contemporary medical practice that is being performed by physicians.¹ Some common examples of emergency procedures and physician fees are listed in Table 213.1. The AMA Relative Value Update Committee assigns a relative value unit (RVU) to the code to reflect the complexity of the service relative to other physician services. The Resource-Based Relative Value Scale ranks services according to three factors: (1) the relative work of the physician, (2) the cost of performing the service, and (3) the risk involved in the service to both the patient and the provider. Each of these factors is assigned a numerical value, which when added together gives a total RVU for the service. This RVU is then multiplied by a geographically adjusted monetary conversion factor to arrive at an actual fee for the services provided (see Table 213.1).

Table 213.1 Sample Fee Schedule for Blue Cross/Blue Shield of Massachusetts Emergency Medicine Procedure and Physician Fees, Effective September 1, 2004

ED, Emergency department.

Evaluation and Management