Planning Notes For Emergency Room Coding, Billing & Reimbursement

Planning Notes For EMTALA and ED Compliance Programs

Planning Notes for EMTALA and ED Compliance Programs

Title: EMTALA and ED Compliance Programs

Objective: To provide a comprehensive overview of EMTALA (Emergency Medial Treatment and Active Labor Act) along with the process of developing a compliance program for the Emergency Department. Specific coding, billing, reimbursement, documentation and service areas relative to compliance concerns will be addressed. The new PBS – Provider-Based Status – rules relative to EMTALA will also be discussed as well as current proposed updates and interpretative guidelines.

Upon Completion the Participants Will:

1. Review the overall process of providing services in the ED and emergency department.

2. Appreciate the implications of the features of the EMTALA statutes.

3. Understand the importance of meeting EMTALA and other ED compliance issues.

4. Review the Charge Master setup for EMTALA services and the associated billing, documentation and reimbursement issues.

5. Be able to delineate the process for developing, implementing an ED Compliance Plan.

6. Understand the ramifications of the False Claim Act (FCA) relative to the provision of services and associated coding and billing for the ER.

7. Appreciate the role of the Charge Master for compliance in the Emergency Department.

8. Delineate specific areas of compliance concern for physicians and hospitals for ER services.

9. Appreciate the E/M coding processes (technical and professional) and their impact on both physician and hospital coding.

10.Appreciate the need for correlating CPT/HCPCS codes on the HCFA-1500 (physician/professional) and the UB-92 (facilities/technical).

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11.Understand the compliance implications of ED physicians working with other physicians in the ER.

12.Appreciate the use of NPPs (Non-Physician Providers) such as PAs, NPs, and CNSs.

13.Recognize the transition that Emergency Departments and ER physicians are experiencing for compliance and payment system changes.

14.Appreciate the role that structuring ER services and the Emergency Department have relative to compliance.

15.Understand how the new Provider-Based Status Rules affect hospitals relative to ED services.

16.Have knowledge of additional sources for further information and assistance.

Audience: Outpatient coders, ER physicians, medical records staff, business office personnel, ER Directors, ER nursing staff, data processing personnel, processing support personnel, insurance clerks, administrative staff, nursing supervisors, and others involved with Emergency Room services.

Method of Presentation: The primary method is Lecture-Recitation with the use of case studies. Interaction and questions from the audience are HIGHLY encouraged. Exercises in the form of coding scenarios will be used.

Course Materials: Extensive Class Notes (including copies of Overhead Transparencies). Class Notes will include copies of selected readings and special materials as appropriate.

Student Materials: CPT Manual (Physician or Hospital Outpatient Services Editions), ER section from Charge Master, ER fee schedule, hospital ER encounter and/or charge forms, and ER compliance plan (if any).

Course Times: 9:00 a.m. to 12:00 noon, 1:00 p.m. to 4:00 p.m.

Outline:

I. Introduction A. Overview of ER Services, Urgent vs. Emergent

B. Overview of EMTALA Statutes C. Overview of ER Physician Coding D. Overview of ER Facilities Coding E. ER Services and Charges in the Charge Master F. ER Documentation, Coding and Reimbursement G. Organizational Structuring and Compliance Requirements H. Overview Of The PBS Rules & Regulations I. Review HIPAA Privacy & Security Rules & Regulations

II. EMTALA A. Frequently Asked Questions B. Definitions C. EMTALA Provisions D. Laws and CFR E. Coverage F. Ability to Pay G. Medical Screening Examination (MSE) H. Managed Care Interface I. Receiving Versus Transferring Hospital J. Penalties for Violations K. Ambulance Considerations L. Malpractice Interface M. Special Situations

III. Developing an Emergency Department Compliance Plan A. Seven Key Elements B. Program Development C. Interface to Corporate Compliance Program D. Coding Policies and Procedures E. Billing Policies and Procedures F. Conducting Audits G. Addressing Complaints

IV. Organizational Structuring of the Emergency Department A. ER Physicians Relationship to Hospitals B. Medical Staff Organization Relationships C. Use of Billing Services D. Types and Levels of Services E. Use of Non-Physician Providers F. Residency Program Implications G. Documentation Systems H. Cardiology/Radiology Relationships

I. Observation in the ER

V. Coding, Billing And Reimbursement Process A. Physician Coding/Billing Process 1. Encounter Form(s) 2. Coding Responsibility 3. E/M Coding Documentation Guidelines 4. Review Function 5. Diagnosis Coding 6. Payment System Considerations B. Facilities Coding/Billing Process 1. Charge Slip(s) 2. Coding Responsibility 3. Facility Use of E/M Codes 4. Review Function 5. Diagnosis Coding 6. Payment System Considerations C. Claim Form Review - HCFA-1500 And UB-92 1. Key Informational Areas 2. Examples

VI. Charge Master Considerations For ER A. Organizing Facilities Charges 1. ER Levels 2. Relationship To ER Triage 3. Developing Charges 4. Supply Considerations 5. Provider-Based Status Charge Master Setup B. Organizing Physician Charges 1. Professional Service Items 2. Establishing Fees - RBRVS 3. Inclusion Of Codes/Modifiers J. Compliance Considerations 1. Descriptions and CPT/HCPCS 2. Assignment of Revenue Center Codes 3. Relationship to the Cost Report 4. Proper Generation of HCFA-1500s and UB-92s

VII. Review of Additional Specific Compliance Areas A. False Claims Act B. Medical Necessity C. Medicare Fraud, Abuse and Anti-Kickback

D. Durable Medical Equipment (DME) E. Self Administrable and Take-Home Drugs and Supplies D. Medical Screening and Triage E. Non-Physician Providers & Incident-To Services F. Provider-Based Status Clinics & ED Services G. HIPAA Privacy & Security Challenges

VIII. Sources For Further Information

Notes: 1. This is an intensive one-day workshop emphasizing practical applications. 2. Case scenarios are used to enhance learning. 3. Reference materials will be made available to class participants as a part of their notes. 4. This workshop is the second day of a two-day sequence of workshops for the ER. The first workshop is "ER: Coding, Billing & Reimbursement". 5. See also the compliance sequence of workshops. 6. CEU Credits are optional.

Revised: February, 1999, March, 2000, February, 2001, May, 2001 File: MyDocuments\Clasouts\2001\0659faf3e111ca09c51795bd05295f15.doc Size: 20480 Printed: 5/27/2002 06:34:00 PM

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