A key Medicare advisory panel is expected to formally call on the CMS to revisit creating a national guideline for coding emergency department visits.
The Medicare Payment Advisory Commission (MedPAC) reached a consensus during its Thursday meeting in Washington to put together a recommendation to HHS to revisit national coding by 2022, citing rampant coding problems under the Outpatient Prospective Payment System. The panel will likely vote on the recommendation during its April meeting.
The CMS could have a firm foundation for assessing and auditing coding behavior if it has a national guideline for ED visits, the panel said.
"There needs to be some guidance to hospitals in how to code in these situations," said MedPAC member Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.
Commission member Brian DeBusk supported a national guideline but with a key caveat.
"I would ask the guideline at least contemplate the concept that if a beneficiary is receiving what amounts to non-emergency care in an emergency department then it be coded to an outpatient clinic," said DeBusk, president and CEO of the healthcare product manufacturer DeRoyal Industries in Tennessee.
He said that he isn't arguing for a site-neutral payment, just a change of the code from an emergency department visit to an outpatient visit depending on the care provided.
MedPAC said that the CMS has tried before to create a national guideline when the OPPS went online in 2000 but were unsuccessful. It did not elaborate on why the agency's scuttled the attempt.
Currently, the agency leaves it up to hospitals to develop their own internal guidelines for reporting an ED visit.
Hospitals can follow models created by the American Hospital Association and the American College of Emergency Physicians or other guidelines for coding.
A report from commission staff that showed hospitals are seeking higher payments from the CMS for ED visits. A hospital codes an ED visit based on five different levels depending on the level of care needed to treat the patient, with one being the lowest level and five the highest.
In 2005, level five ED visits made up about 10% of all ED visits to hospitals, according to a MedPAC analysis of cost statistics from the CMS. But in 2017, the number of level five visits increased to 30%, MedPAC found.
The panel also looked at data from the National Hospital Ambulatory Medical Care Survey from 2011 to 2016 showing an increased use in screening services such as CT scans and EKGs for ED visits but no change in lab tests and procedures.
MedPAC's analysis said that there is no clear explanation for the change in coding that has taken place in recent years.