Medicare panel considers national coding standard for ED visits

The Medicare Payment Advisory Commission, an independent federal agency that advises Congress on Medicare, is considering a recommendation to establish national guidelines for hospital emergency department coding.

Hospitals now use internal guidelines for coding ED levels, which reflect varying amounts of resources used for emergency care. The higher the level of ED care, the more money hospitals get from Medicare.

The commission is expected to recommend that CMS set national, uniform guidelines for coding ED levels.

In considering the recommendation, the commission cites coding issues under the Medicare Outpatient Prospective Payment System. 

A MedPAC analysis of cost statistics from the CMS showed that coding of ED visits shifted to higher levels, such as level 5, between 2005 and 2017, according to a March 7 presentation by commission staff. The commission also examined data from the National Hospital Ambulatory Medical Care Survey showing that screening services such as CT scans and EKGs increased for ED visits from 2011 to 2016, but there was little change in lab tests and procedures during that period.

Commission staff said is not a clear explanation for the coding change, but a high concentration of level 5 ED visits with the same patient conditions treated likely indicates that Medicare pays hospitals too much for many patients.

MedPAC argues that national guidelines for hospital ED coding could help ensure Medicare payments to hospitals accurately reflect hospital resources used for ED care and provide hospitals with clear ED coding rules.

The commission will likely readdress this issue in April to vote on whether to send this as a formal recommendation to Congress.


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