MAC Medical Reviews and ER Facility Levels

on Tuesday, 18 September 2018. All News Items | Outpatient Services | Medicare Coverage

Not a Bell Curve

There is not a lot of activity on the Medicare Administrative Contractor (MAC) medical review front this month. The various MACs are proceeding at different rates and providing information in different formats concerning the new Targeted Probe and Educate (TPE) program. One of the main aspects of the program is to individualize education and present it to providers one-on-one. This has resulted in different interpretations by the MACs on what information to place on their websites:

Palmetto (JJ and JM), CGS (J15) and Novitas (JH and JL): These MACs have listings of active topics and results of some reviews posted on their websites. Results generally include the major errors and suggestions for avoiding denials. Some of this information is confusing, since results include both numbers of compliant/non-compliant providers and error rates by state, but the suggestions for avoiding errors is helpful information for all providers. I, for one, really appreciate this type of detail on the MAC websites.

First Coast (JN) and WPS (J5 and J8): TPE topics listed on their websites, but no review results yet. WPS does offer a number of articles on documentation guidance for their review topics which is also helpful information for all providers.

NGS (J6 and JK) and Noridian (JE and JF): There is general TPE information on their websites, but no specific review topics have been posted.

This week I would like to focus on WPS’s review topic of Facilities Billing Emergency Room Services CPT Codes 99281-99285. I was surprised to see this TPE topic because there are no national visit guidelines for the selection of a specific ER facility level of care CPT code. For years, many thought CMS would eventually publish such criteria, but they have not. CMS instructs individual hospitals to develop internal criteria for charging E&M levels based on the following guidelines that appeared in the 2008 Outpatient Prospective Payment System (OPPS) Final Rule:

  • Reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
  • Be based on hospital facility resources, not on physician resources.
  • Be clear to facilitate accurate payments and be usable for compliance purposes and audits.
  • Meet the HIPAA requirements.
  • Only require documentation that is clinically necessary for patient care.
  • Not facilitate upcoding or gaming.
  • Be written or recorded, well-documented, and provide the basis for selection of a specific code.
  • Be applied consistently across patients in the emergency department to which they apply.
  • Not change with great frequency.
  • Be readily available for MAC review.
  • Result in coding decisions that could be verified by other hospital staff, as well as outside sources.

To summarize, the levels should be related to the hospital resources used, be clear and verifiable by outside reviewers, not promote up-coding, be supported by the usual ER documentation, and be consistent.

Also discussed in the 2008 OPPS Final Rule (FR) was the consideration of separately payable services in selecting the ER facility level of care. At one time, assigning your ER level based on procedures for which you also received separate payment was considered “double-dipping” and was discouraged. In the 2008 FR, CMS stated, “In the absence of national visit guidelines, hospitals have the flexibility to determine whether or not to include separately payable services as a proxy to measure hospital resource use that is not associated with those separately payable services. The costs of hospital resource use associated with those separately payable services would be paid through separate OPPS payment for the other services.” The discussion goes on to suggest hospitals contact their local MAC for additional guidance.

Hospitals use different definitions and systems to define their ER visit levels. A number of hospitals use American College of ED Physicians (ACEP) criteria; some use the modified AHA / AHIMA criteria; some hospitals use computer-generated or manually calculated systems based on an intervention point system; other options are patient acuity or time-based. Medicare does not prescribe that a particular system be used as long as the above principles are followed. However your facility chooses to select ER visit facility level codes, how do you and outside reviewers (such as a MAC) evaluate your coding to ensure it is accurate, appropriate, and compliant?

One consideration in evaluating your ER levels is the distribution of the CPT codes. In the 2008 FR, CMS evaluated the use of hospital-specific criteria for ER level selection based on a bell curve for the codes submitted. See a prior Wednesday@One article for more information about the code distribution. CMS stated in that rule, “We would not expect individual hospitals to necessarily experience a normal distribution of visit levels across their claims, although we would expect a normal distribution across all hospitals as currently observed…We understand that, based on different patterns of care, we could expect that a small community hospital might provide a greater percentage of low-level services than high-level services, while an academic medical center or trauma center might provide a greater percentage of high level services than low-level services.” An individual hospital’s ER level distribution does not have to be a bell-curve, but would be expected to be a reasonable graph that fits with the acuity of the facility’s ER patients and services.

Here are some examples of the variation in distribution of ER levels seen in similar types of hospitals. Numbers 1-5 correlate respectively with ER level codes 99281-99285. These volumes were obtained from Medicare data from our sister company RealTime Medicare Data (RTMD). I am not saying any of these distributions are right or wrong – this is something each hospital should evaluate internally. You understand the types of patients coming through your emergency room – practically, does your ER level distribution look appropriate to you?

Chart OneChart TwoChart ThreeChart Four

Along this same line, PEPPER reports (Program for Evaluating Payment Patterns Electronic Report) for short-term acute care hospitals added a new measure related to ED facility levels beginning with the July – September 2017 quarter reports. This Emergency Department Evaluation and Management Visits (ED E&M) measure provides the ratio of Level 5 ED visits to all ED visits reported by a hospital and compares your data to that of other hospitals at your state, MAC jurisdiction and national levels. This will allow you to evaluate if you are reporting a higher or lower percentage of Level 5 ED visits (CPT 99285) than your peers. In some cases, there may be valid reasons for being an outlier, but this is another way to assess the appropriateness of your ED levels. If you cannot think of a reason for being higher or lower than other hospitals, a deeper evaluation of your system for assigning ED levels is warranted. See a prior Wednesday@One article for more information about this PEPPER target.

Think about whether your ER levels correlate with the acuity of a patient’s condition. An ER visit for a minor upper respiratory infection should be a lower visit level than that of a broken bone, which should be less than a possible heart attack. Also, does your internal criteria make sense and flow appropriately from the lowest to the highest levels?

Other considerations for evaluating your ER levels can be found on the WPS website. Hopefully, WPS will publish some results information as they move forward with this review. In the meantime, they have provided some documentation guidance for a successful review of CPT codes 99281-99285. According to their article, documentation should include:

  • The number and type of interventions under the facility charge
  • The visit record showing the signs/symptoms that support the medical necessity for the interventions
  • The internal guidelines used to determine the HCPCS equivalent CPT code (99281-99285) for the hospital resources being billed (HCPCS to CPT conversion guidelines)

It will be interesting (or possibly frightening if your hospital is targeted) to see how the WPS audit plays out.

  • Will WPS deny claims they believe are coded at an inappropriate level or adjust the payment to a code they think is more appropriate?
  • Will WPS accept hospitals’ criteria at face value or will they question the appropriateness of the criteria itself?
  • Will other MACs follow WPS and audit ER facility levels in the future?
  • Some commercial insurers have targeted ER facility levels – will they continue, back off like Anthem did, or will this practice expand?
  • And most importantly, how should hospitals prepare for these audits?

My suggestions are to make sure you have clear and reasonable ER facility level of care criteria, that you “feel good” about your ER facility levels overall, documentation clearly supports the levels selected, and you think you could defend your level selections to an outside auditor.

MAC medical review activity since last month is listed below.

MACService DescriptionService CodeDateError/Denial RateStatus
Palmetto JJ Denosumab HCPCS J0897 8/16/2018   Active (new)
Novitas JH Cardiovasc NM CPT 78451-78454, 78466-78483, 78494, 78496, 93015-93018 6/1/2018 Reprobe Prior to TPE
JH Round 2 Results
Round 3 (June 2018)


Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.


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