Leveling of Emergency Room Services

Date: 06/05/20

A Centene policy last reviewed on 09/01/19 is being adopted locally effective 09/01/2020.

Coordinated Care of Washington, Inc. has adopted a program integrity strategy that will provide appropriate levels of reimbursement for services indicating lower levels of complexity or severity rendered in the emergency room. This policy will have application at hospitals, free-standing emergency centers, physicians or other qualified health professionals.

The Centers for Medicare and Medicaid Services (CMS) affords states the flexibility to independently develop reimbursement methodologies for the use of emergency department services for lower levels of complexity or severity.

When a hospital, free-standing emergency center or physician bills a Level 4 (99284) or Level 5 (99285) emergency room service, with a diagnosis indicating a lower level of complexity or severity, the health plan will reimburse the provider at a Level 3 (99283) reimbursement rate. Critical Access Hospitals are exempt from this policy when they are reimbursed on a ratio of cost-to-charges (RCC) basis.

A coding algorithm was developed with the advice of a panel of emergency department and primary care physicians and based on an examination of a sample of almost 6,000 full emergency department records. Data from these records was used to classify each case into one of four categories.

These classifications were then mapped to the discharge diagnosis of each case to determine for each diagnosis the percentage of sample cases that fell into these four categories. Coordinated Care’s claims processing system incorporates a list of diagnoses developed by medical directors and compared to the algorithm to adjudicate emergency department claims.

The claims processing system looks for diagnoses that involve a lower level of complexity or intensity of services (i.e. that are never or rarely associated with Levels 4 or 5 severity).

If the diagnosis code classification falls into a categorization indicating a lower level of complexity or severity, services billed at a Level 4 or Level 5 severity code, will be reimbursed at the Level 3 emergency department reimbursement level. A provider may appeal if the provider disagrees with how the claim was adjudicated.

Documentation Requirements for Providers: The patient’s primary discharge diagnosis should be billed in the first diagnosis position on the emergency room claim form.

Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

References:

  • Current Procedural Terminology (CPT®), 2016
  • Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services.

Why Did My Emergency Room Visit Cost So Much?

An emergency room sign at a hospital

Emergency room visits are notoriously expensive. Just a few hours in the ER can cost you thousands of dollars, with or without insurance.

But how is your ER visit cost calculated, and how can you tell whether your hospital bill is correct? 

We scored some insider tips from Goodbill medical coding expert Christine Fries, who has analyzed thousands of ER hospital bills for accuracy. Here are answers to frequently asked questions we get from Goodbill customers about how to understand and vet ER visit costs.

Why did I get 2 bills for my ER visit?

level 4 er visit meaning

Patients are usually surprised when their first ER hospital bill is quickly followed by a separate hospital bill with similar-sounding charges but different amounts. This is normal and a byproduct of how hospitals bill patients for the services rendered at the hospital, Fries says. 

The institutional bill, also known as the facility bill, charges you for the procedures, tests, and administrative costs from the hospital. 

The professional bill, also known as the physician bill, charges you for the work and time of the physician who treated you. This generally includes services from doctors, anesthesiologists, or specialists who are affiliated with the hospital but aren’t employed by the hospital. 

Expect to get two bills from your ER visit — one for facility charges, and the other for professional or physician charges.

For more information on the different types of hospital bills, see our itemized bill guide . Goodbill currently helps patients negotiate institutional bills, not professional bills, so our guidance below pertains to institutional bills only. 

My diagnosis turned out to be minor. Why was I charged so much?

It’s important to remember that your ER visit costs are based on the symptoms you first describe upon entering the hospital, not your eventual diagnosis, Fries says.

When a patient walks into the emergency room complaining of chest pains, for example, the hospital’s objective is to run tests and administer procedures that can help rule out life-threatening conditions. Even if the doctor ends up discharging the patient with a non life-threatening diagnosis like indigestion, the hospital has already spent the resources to rule out more severe possibilities like a heart attack.

Your ER visit costs are based on the symptoms you first describe upon entering the hospital, not your eventual diagnosis.

“Look at your symptoms first, not what you were diagnosed with,” Fries says. “The level of your ER visit is guided by the symptoms you described, and by the tests the hospital thought were needed based on those symptoms.”

Why was I charged for an ‘ER Visit Level’ 3, 4, or 5? Is this based on severity?

Hospitals will bill you for a line item called “ER Visit Level” that is based on the complexity of your treatment. ER visit levels range from 1-5: ER visit level 1 is the most mild, while ER visit level 5 is the most severe. The level also determines how much the hospital can charge you, from least expensive to most expensive. You may sometimes hear ER visit levels described by their corresponding Current Procedural Terminology (CPT) codes of 99281, 99282, 99283, 99284 and 99285. 

To decide the proper ER visit level, hospitals typically follow certain guidelines from the American College of Emergency Physicians (ACEP) . ER level 1-2 visits are reserved for treatment of mild cases like bug bites and sunburns. The majority of ER visits fall between ER visit levels 3-5, with ER visit level 4 being the most common, Fries says.

“Most emergency room claims will qualify as a 99284, because you only need something as simple as IV fluids to get you there,” Fries says.

The majority of ER visits fall between ER visit levels 3-5, with ER visit level 4 being the most common.

Here’s a simple rule of thumb for determining whether your ER visit level was correctly assigned.

ER Visit Level 4

‍ An ER visit level 4 typically requires a minimum of two diagnostic tests — like a lab plus an EKG, or a lab plus an X-ray. Or, any administration of fluids through IV will automatically qualify your visit as an ER visit level 4.

ER Visit Level 5

‍ An ER visit level 5 typically requires a minimum of three diagnostic tests — for example, a lab plus EKG and X-ray. Or, any type of imaging scan like a CT scan or MRI where a patient must ingest or be injected with contrast material, will automatically qualify your visit as an ER visit level 5.

level 4 er visit meaning

‍ I’m not pregnant. Why did I get charged for a pregnancy test?

Many female patients get frustrated when they’re charged for a pregnancy test, even when they’re absolutely certain they’re not pregnant. But this is standard practice and a way for hospitals to protect against unknown pregnancies, Fries says. 

If you’re an adult pre-menopausal female, you can count on being asked to do a urine or blood pregnancy test before the hospital will treat you. It’s too risky to both the patient and hospital to administer injections, scans or drugs in the off chance that a patient is unknowingly pregnant. 

If you're a female, expect to get a pregnancy test during your ER visit — even if you're not pregnant.

On your itemized ER bill, your pregnancy test will usually show up with a description like “human chorionic gonadotropin (hCG),” which is the hormone being tested. This charge will generally fall under the CPT codes 84702 or 84703 if it’s a blood test, or 81025 if it’s a urine test. 

What are some other common ER services I might see on my hospital bill? 

Here are a few common procedure names that often show up in your ER visit costs, and what they mean in plain English:

Metabolic panel

‍ This is a bundle of lab tests run from a single blood draw. Patients may get a “basic” metabolic panel under CPT code 80048, or a “comprehensive” metabolic panel under CPT code 80053. These panels cover a set of individual tests that might otherwise be individually charged. For example, a “comprehensive” metabolic panel must include testing for all of the following: 

  • Carbon dioxide
  • Phosphatase, alkaline
  • Transferase, alanine amino
  • Transferase, aspartate amino
  • Urea nitrogen

Venipuncture

‍ Any time you get your blood drawn through a needle, this charge under CPT code 36415 is the line item that bills you for the needle.

‍ This test under CPT code 83690 measures your levels of lipase, which is an enzyme that helps break down fat in your intestines. Your lipase levels may be elevated if you have pancreatitis, which is an inflammation of the pancreas gland.  

What are some ER visit cost errors I should look out for?

When analyzing a patient’s ER visit costs for errors, Fries says she goes straight to one place first: Hydration services. If you recall being administered fluids through an IV bag, chances are you got hydration services during your ER visit.

“Hydration services should always be questioned,” Fries says.

Coding guidelines require that the two CPT codes for this service, 96360 and 96361, meet a minimum time requirement of 31 minutes in order for one unit to be billed. These 31 minutes must also be “stand alone” — meaning that the administration of the service cannot overlap with any other type of infusion service. Often, hospitals don’t meet these requirements, rendering the charge unbillable.

Hydration services are a common source of errors in ER hospital visit costs. You can tell if you're being overcharged by checking your medical record.

To verify whether you’re being charged properly, you’ll need your medical record, Fries says. Look for hydration service “start” and “stop” times, which are usually included in the Medication Administration Report (MAR) section of your record. If the hydration service duration is less than 31 minutes of standalone time, you have a strong case to dispute the charge with your hospital. To find out how to get your medical records online, visit our Medical Records guide .

I don’t see any CPT codes on my bill. How can I get them?

CPT codes are the common language used across all hospitals to describe a certain procedure. They’re what enables our medical coders at Goodbill to analyze hospital bills for errors, line item by line item. They also help us compare prices apples-to-apples across hospitals.

CPT codes are the standard language used to describe a certain procedure across all hospitals. They're key to helping you identify errors or inflated charges in your ER hospital bill.

Unfortunately, the hospital bill you get in the mail is most likely a consolidated summary of your ER visit costs and won’t include CPT codes. You’ll need an “itemized bill” from your hospital to get a line-by-line breakdown of each charge, complete with the CPT code and cost. 

The good news is that you’re legally entitled under HIPAA to get access to this information. To learn more about your patient rights and how to obtain your itemized bill, check out our Patient Right of Access guide .

Are there other topics you’d like us to cover? Email us at [email protected] and let us know.

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What to expect in the emergency department

“The emergency department is an area in the hospital where we can quickly assess patients, make them better, or decide they’re going to need additional testing or management and admit them to the hospital,” says Jeffrey Oyler, M.D. , an emergency medicine physician at Piedmont Atlanta Hospital .

Every patient who visits the emergency department (ED) will go through triage, which allows the ED team to establish the severity of that person’s condition. Triage takes into account the patient’s vital signs, as well as his or her complaint. Dr. Oyler says measuring the patient’s vital signs is the most crucial component of triage because these signs are essential to assessing the patient and are something that cannot be faked. The patient is then categorized based on the Emergency Severity Index:

  • Level 1 – Immediate: life-threatening
  • Level 2 – Emergency: could be life-threatening
  • Level 3 – Urgent: not life-threatening
  • Level 4 – Semi-urgent: not life-threatening
  • Level 5 – Non-urgent: needs treatment as time permits

“It’s hugely important for us to establish who is the sickest, so we can provide the interventional care they need immediately, then work our way down the list as fast as we can,” says Dr. Oyler. Based on the assessment by the triage nurse, the patient will either be:

  • Taken to an exam room. If all rooms are full, that person will be next in line for a room. Dr. Oyler emphasizes that patients are not seen in the order of arrival, but based on the severity of their condition.
  • Offered a fast-track service. The fast track does not have all of the capabilities of the emergency department, but is intended to help patients with minor emergencies get through the system. People in the waiting room may see other patients with minor injuries being called back before those with more serious injuries, but they are actually being treated in the fast-track area, Dr. Oyler explains.

Behind the waiting room doors

“A quiet waiting room is something we ideally love to have, but it is not a reflection of what is going on in the back,” says Dr. Oyler. “You can have one person or 20 people in your waiting room, but you could have complete chaos in the back with very, very sick patients.” Although the ED waiting room may not seem busy, the behind-the-scenes ambulance bay can bring in patients at all hours of the day. “You can have an incredibly long wait in our emergency department if you show up with a non-life-threatening condition that could have waited for treatment at your primary care physician’s office the next day,” he says. “We are sensitive to the fact that you are waiting,” says Dr. Oyler. “We want you to get back to a room and be seen as fast as possible, but we’re also prioritizing care for people who absolutely have to have it right then and there.” Dr. Oyler stresses the importance of patience if your illness or injury is not life-threatening. “We know you’re suffering and it’s not what we desire, but when your time comes, you’re going to get the service you wanted.” If your condition is not an emergency, you can save time and money by visiting an urgent care center or your primary care physician’s office. Insurance co-pays are usually more expensive at the emergency department compared to co-pays at other facilities. For more information on emergency services throughout the Piedmont system, visit our locations map to choose an emergency room near you .

Need to make an appointment with a Piedmont physician? Save time,  book online .

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Coding tips: Level 3 vs. 4 evaluation and management

To payers, these visits tell a completely different story about the work that’s required to treat a patient.

The difference between a level 3 and level 4 office visit might not seem like much, but to payers, these visit types each tell a completely different story about the work that’s required to treat a patient.

When physicians report a level 4 evaluation and management (E/M) code, they’re telling payers they should be paid more because their patient requires medical management for an exacerbation of an existing chronic condition, a complication, or a new problem, says Raemarie Jimenez, CPC, vice president of membership and certification solutions at AAPC in Salt Lake City, Utah. Payers may deny level 4 E/M codes for patients who respond well to treatment and are generally well-managed, she adds.

When using an EHR, though, it’s easy for physicians to default to a level 4 E/M code that might not be justified, says Jimenez. That’s because the EHR pulls information forward that might not be clinically relevant or even pre-populates information that falsely inflates the actual work the physician performs. “The computer just picks up on keywords and boxes, but it’s not smart enough to realize that a visit might be over-documented,” she adds.

For example, pulling information forward, such as a comprehensive family history or a complete review of systems, can inadvertently drive a level 4 E/M code when the nature of the presenting problem (e.g., otitis media) in no way supports this level of service, explains Jimenez. Over time, it may appear to payers that a physician is upcoding as compared to peers.

To avoid payer scrutiny, Jimenez advises physicians always to ask themselves these three questions before assigning a level 4 E/M code:

1. Is this patient sicker than most of the patients I see? 2. What specifically elevates the level of effort that’s required to treat this patient? Have I documented this information in the record? 3. Have I reported the most specific ICD-10-CM diagnosis code to justify patient severity?

Physicians should also know whether their EHR might be putting them at risk for upcoding. Jimenez says to consider these three questions:

1. Does the EHR auto-populate information and require physicians to deselect what’s not pertinent to the visit? For example, an EHR might auto-populate a complete review of systems and require physicians to deselect the systems they don’t review with the patient. This practice is extremely risky because physicians don’t often remember to review the information or they may simply forget to deselect it, says Jimenez. Best practice is for physicians to manually select what they want to bring forward. It shouldn’t happen automatically, she adds.

2. Do diagnosis-specific templates require physicians to perform certain tasks every time they see a patient? All work must be clinically relevant, says Jimenez. “Physicians shouldn’t be forced to do something just because the EHR is telling them to do it. Everything they do should be based on their own clinical judgment.”

3. Does the EHR require physicians to bill a certain code? The code that the system calculates may not be accurate, and physicians always need the ability to override it when necessary, says Jimenez. She provides the example of a physician who includes rule-out diagnoses for continuity-of-care purposes. If the physician isn’t actively managing these conditions, they shouldn’t be counted toward the visit’s E/M level. If the EHR gives credit for this information, physicians need to recognize that the E/M level may be inflated, and they should override the code manually, she says.

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A Quick Guide To Identifying Level-4 Visits

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Evaluation and management (E/M) service coding and documentation has to be the issue that physicians despise reading about the most. As we all understand, the “guidelines” for code and documentation are a tangle of regulations that encourage down coding by keeping the laws unclear and the severe penalties. The “new framework” for documentation standards, which is anticipated to be issued later this year, may or may not clarify the regulations. So far, revision hasn’t made the process any simpler to use.

A Quick Guide To Identifying Level-4 Visits (99214)

According to CPT, 99214 is recommended for an “office or another outpatient visit for assessing and caring of an established patient, which needs at least two of these three essential aspects: a complete history, a thorough analysis, and medical decision making of varying capabilities.

99214 General Guidelines

Consider 99214 in any of the following circumstances:

  • If the patient develops a new Problem that might result in substantial morbidity if left untreated.
  • If the patient has three or more previous issues.
  • If the patient develops a new issue that necessitates a medication.
  • If the patient has three stable problems that need medication renewals, or if the patient has one steady-state and one poorly managed problem that requires drug refills or changes.

Documentation

To keep our use of level-4 codes more uniform and decrease the amount of time spent on coding, I created the “Level 4 Reference Card” for myself, my colleagues, and our residents. The card’s front includes the primary requirements that your documentation must fulfil to classify a visit as a 99214 (any two of the following: a complete history, a detailed exam, and moderately tricky decision making), and it describes the materials that must be documented to satisfy each requirement. It also has a box that describes the requirements for a level-4 visit with an existing patient (99214) vary from a level-4 appointment with a new patient (99204). The reference card can be used in at least two main ways: First, using the card attached to the wall where you dictate, you may follow along while you write your note, ensuring that your dictation contains all of the information that suggests your level-4 code option. You can also use the reference card as a guide for performing internal audits of other doctors’ records.

Internal coding and documentation audits may strike you in the same way dental appointments hit the general public, but don’t dismiss their importance. Every doctor in our 22-person group evaluates five dictations every month, and every physician is a better coder. In our practice, the physicians are expected to be the coding specialists. It’s also crucial to enhance the quality of your coding. We’ve discovered that adding the CPT codes to the bottom of all our dictations and highlighting them on the superbills is a valuable tip. As a result, we may conduct our mini-audits to confirm that our documentation validates our coding when we receive our dictations. If we discover that we have under coded, we usually write off the penalty. If we find out that we have coded too high, we may file a corrected claim (and our procedure is to hold all our level-4 and -5 Medicare charges until the dictation has been reviewed). The actual value of this practice is that it helps all of us better coders.

Level 4 Visits With New Patients

A detailed history and physical exam are required for a 99214, whereas a complete history and physical exam are required for a 99204. In terms of documentation, the discrepancies are reflected in four ways:

  • All three essential requirements (history, physical exam, and medical decision making) must be satisfied for a 99204. Only two of the three basic requirements are required for a 99214.
  • The system review for a 99204 must encompass at least ten systems or bodily parts. A 99214 requires only two studies.
  • The previous family and societal history for a 99204 must include all three sectors. A 99214 requires one area.
  • The physical test for a 99204 must encompass at least 18 shots from at least nine systems or physical locations. At least 12 rounds from at least two systems or bodily areas are required for a 99214.

When we neglect to follow the guidelines, we may fail to include information collected during the visit in the patient record – information that we believed was important due to the patient’s condition.

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Efficient MD / December 17, 2018

A Simplified Explanation of Emergency Department E/M Coding

level 4 er visit meaning

The way medical charts are coded and billed is unnecessarily convoluted, and you have the Centers for Medicare & Medicaid (CMS) to thank for that.  They are the ones who created the coding system that is used to assign an Evaluation & Management (E/M) level to our charts. Each chart is billed using a Current Procedure Terminology (CPT) code based on E/M levels 1-5.

Billing and coding is an extraordinarily boring topic.  I’m actually impressed that you’ve read this far. But I think it’s worth taking a little time to understand the basics in order to chart as efficiently as possible.  A level 5 chart does not necessarily require that you write a novel to meet the coding criteria. It is also possible to write a very long, thorough chart and still only get credit for a level 3 or 4 chart.  Unless you know the elements of the chart that count towards that level of coding, you may end up doing a lot of unnecessary work.

Rather than review the criteria for every component of each of the 5 CPT codes, which would be time-consuming and painful for you to read, I thought it would be most beneficial to go through a sample level 5 (CPT code 99285) ED visit, pointing out the potential pitfalls where your chart could possibly be down-coded to a level 4.

level 4 er visit meaning

There are only 3 components that determine the E/M level:

1. HISTORY

2. PHYSICAL EXAM

3. MEDICAL DECISION MAKING

As I go through this sample case I will demonstrate the minimum amount of documentation needed for the chart to be coded as a level 5 chart.  I’m certainly not telling you to only document the minimum just to hit the level 5 criteria, as you should thoroughly chart  everything that is necessary for each patient. This is simply an exercise to illustrate the minimum documentation that would be needed solely for coding purposes.  Next to each of these 3 components, I will list in parentheses the minimum criteria required for that particular component. Keep in mind that the lowest scoring of the 3 components will determine the E/M level for the entire chart.

HISTORY ( HPI: Chief Complaint, 4+ elements, ROS: 10+ elements, PFSH: 2 of 3 elements)

The history component consists of 4 elements: chief complaint (CC), History of present illness (HPI), Review of systems (ROS), and Past medical, family and social history (PFSH).  A level 5 chart is designated “comprehensive” and includes 4+ HPI elements, 10+ ROS elements, and 2 of the 3 PFSH elements. What do you do if the patient is unable to provide a history because they are altered or intubated?  Or what if the patient refuses to give a history? Add a qualifier describing the reason for the limitation, such as “patient is unable to provide history secondary to…”. This will apply to all elements of the history component.

  • CC – This is a mandatory element for all charts, regardless of CPT level.
  • Modifying Factors
  • Associated Signs/Symptoms

*In lieu of the HPI elements you could also document the status of 3 chronic or inactive conditions.

  • Constitutional
  • Ears, Nose, Mouth, Throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Integumentary (skin and/or breast)
  • Neurological
  • Psychiatric
  • Hematologic/Lymphatic
  • Allergic/Immunologic

A level 5 chart must document at least 10 organ systems.  Your EMR may have a button you can click that states something to the effect “all other systems reviewed and are negative.”  Clicking this button will technically satisfy the 10+ organ system ROS criteria, but doing so attests that you actually reviewed every organ system with the patient.  A word of caution: don’t document something that you didn’t do!

  • Past Medical History (PMH) – Includes experiences with illnesses, operations, injuries, and treatments.
  • Family History (FH) – Review of medical events, diseases, and hereditary conditions that may place the patient at risk.
  • Social History (SH) – Includes sexual history, alcohol/drug use, employment, and education.

A level 5 chart must include at least one item each from 2 of the 3 components .  These are often documented by another staff member, such as the triage nurse.  If these are documented by another staff member they still counts toward your coding as long as you attest that their notes were “reviewed and verified by me.”

Let’s get to the sample case:

John Doe is a 60yo male with a history of hypertension and diabetes who presents to the emergency department complaining of chest pain .  He describes the pain as a “pressure” sensation in his left chest that began at 4pm today while walking .   He notes that his father died of an MI at age 65 .

This brief paragraph includes the chief complaint (chest pain), 4 HPI elements: quality (“pressure”), location (left chest), duration (began at 4pm), and context (while walking);  past medical history (history of hypertension and diabetes) and family history (father died of an MI at age 65). As long as you include your 10 ROS elements, you’ve met the minimum level 5 criteria for the HISTORY component of the chart!  If this were a real patient you would clearly want to include more details regarding his presentation, but again, I’m using this example just to illustrate that you don’t need to write a novel for your chart to be coded at a level 5.

Pitfall – Keep in mind that the PFSH consists of 3 distinct components: PMH, FH and SH.  You could list 10 medical conditions that the patient is suffering from but these all only count for 1 of these elements, the PMH.  If the entire chart meets criteria for a level 5 chart but only 1 of these 3 elements is documented, such as failing to document that the patient is a smoker or has a significant FH of heart disease, the HISTORY component of the chart will be downcoded to a level 4, which means the entire chart is downcoded to a level 4.

PHYSICAL EXAM ( 9 systems, with 2 bullets per system )

A level 5 chart requires a “comprehensive” physical exam, which consists of 9 systems, with 2 bullets per system.  CMS recognizes the following 14 systems as part of the physical exam:

  • Ears, Nose, Mouth and Throat
  • Chest (Breasts)

If you’d like to see the bullets that are within each of these systems, they can be found at the CMS website here .  I’ve found that the most efficient way to ensure that your chart meets level 5 coding criteria is to create a “normal” templated exam that includes the minimum 9 systems with 2 bullets per system and modifying it as needed.  However, if you choose to do this, be cautious! You need to know exactly what is in your templated exam and you must review it for each patient to ensure that you have not documented something that you did not actually do.  Again, don’t document something that you didn’t do .

MEDICAL DECISION MAKING   ( High )

The MDM section of your note is the most nebulous of the 3 components when it comes to understanding how it is coded.  There are 3 elements that are considered here, with the final code being based upon the highest 2 of the 3 following elements:

  • The number of possible diagnoses and/or the number of management options that must be considered (I will refer to this as DIAGNOSES )
  • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed (I will refer to this as DATA )
  • The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options (I will refer to this as RISK )

DIAGNOSES – The highest score for this category is “extensive,” which is needed to bill as a level 5 chart.  If you are seeing a patient who is presenting with a problem that is new to you , the provider, and you are pursuing a workup of the presenting problem, this fulfills the “extensive” criteria.  If you are seeing the same patient, but not pursuing any workup, this component would be categorized as “multiple” rather than “extensive” and coded as a level 4 rather than a level 5.  As an emergency provider, nearly every patient you treat will be presenting with a problem that is new to you . A rare exception to this may be someone who is returning for a scheduled re-check.  

DATA – Again, the highest score for this category is “extensive,” which corresponds to a level 5 chart.  This section is calculated using a scoring system, with a score of 4 or greater needed to be considered “extensive.”  Here is the breakdown of the scoring :

  • Review and/or order of clinical lab tests – ( 1 point )
  • Review and/or order of radiology tests (excluding cardiac cath and echo) – ( 1 point )
  • Review and/or order of medical tests (PFTs, colonoscopy, cath, echo) – ( 1 point )
  • Discuss tests with performing physician (e.g., You discussed a colonoscopy result with the gastroenterologist.  You must document this discussion in your note.) – ( 1 point )
  • Independent review of image, tracing, specimen* – ( 2 points )
  • Reviewed and summarized old records or history from a person other than the patient (e.g., If you spoke with a consultant, even informally, this counts!  Just be sure to document the conversation in your note.) – ( 2 points )

* If documenting an ECG, your interpretation must include at least 3 of the 6 elements: rate/rhythm, axis, intervals, ST-segment changes, comparison to prior, summary of the patient’s clinical condition

RISK – Level of risk is scored from “minimal” to “high,” with a score of “high” needed to bill as a level 5 chart.  The risk score is calculated using a risk table, which is unwieldy and probably not worth your time to study. For our purposes, to understand what qualifies as a level 5 chart in the ED, suffice it to say that a patient who is sick and requires urgent intervention typically qualifies as a “high” level of risk.  Conditions that fall under this category include acute MI, pulmonary embolism, severe COPD exacerbation, multiple trauma, seizure, CVA, and psychiatric patients who are a threat to themselves or others.  Also note that any patient who receives a parenteral-controlled substance qualifies as “high” risk .  

Let’s revisit our patient who is presenting to the ED with chest pain.  His chief complaint is a problem that is new to us .  If we decide to pursue a workup for his chest pain (e.g., labs, ekg, cxr, etc.), the DIAGNOSES component of the MDM would meet the “extensive” criteria.  Now, in order for the MEDICAL DECISION MAKING element of the chart to qualify for level 5 billing, we just need either the DATA or RISK component to also meet the threshold for a level 5 chart.  Remember, you need 2 of the 3 components of the MDM ( DIAGNOSES, DATA and RISK ) to satisfy the highest level of billing in order for the MDM element to be billed as a level 5 chart.

Remember, the DATA component of the MDM is calculated based on points derived from various elements of the workup.  We need at least 4 points to satisfy the “extensive” level of billing required for a level 5 chart.  For this patient, if we order labs ( 1 point ), a chest x-ray ( 1 point ), and then document our interpretation of the chest x-ray ( 2 points ) we have a total of 4 points, which is sufficient to reach the “extensive” level of billing for the DATA component.

At this point the MDM element of the chart satisfies the billing criteria for a level 5 E/M code because 2 of the 3 elements of the MDM , the DIAGNOSES and DATA components, meet the maximum level of billing.  The RISK component of the MDM does not even need to be considered because the MDM can be billed as a level 5 chart without it.  However, if you had treated your patient’s chest pain with morphine during the encounter, this would have automatically bumped the RISK component to the maximum level, “high.”  If this were the case, all 3 of the MDM elements would satisfy the criteria for a level 5 chart, though only 2 of these 3 are needed.

To recap, a level 5 E/M chart requires that all 3 components of the chart, the HISTORY, PHYSICAL EXAM, and MDM, meet their respective maximum coding criteria.  Here are the 3 components with their respective level 5 billing criteria and the items from the chart that fulfill them:

level 4 er visit meaning

CRITICAL CARE TIME

Critical care documentation is a special snowflake that warrants its own section.  CMS defines critical care as a medical condition that “impairs one or more vital organ systems” and is one in which “there is a high probability of imminent or life-threatening deterioration in the patient’s condition.”  They further note that the physician should provide “frequent personal assessment and manipulation” of the patient’s condition.

Here is a list of diagnoses that suggest critical care billing may be appropriate:

  • Active seizures
  • Acute altered mental status
  • Acute GI bleed
  • Acute psychosis with agitation
  • Acute stroke
  • Cardiac arrest
  • Delirium tremens
  • Ectopic pregnancy
  • Hyperkalemia requiring treatment
  • Hypovolemic shock
  • Intracerebral hemorrhage
  • Moderate to severe asthma
  • Moderate to severe CHF
  • Overdose requiring antidotes or reversal agents
  • Pneumothorax
  • Pulmonary embolus
  • Rapid atrial fibrillation
  • Respiratory distress requiring non-invasive positive pressure ventilation
  • Respiratory distress requiring intubation
  • Severe anemia requiring blood transfusion
  • Suicidal ideation immediate threat
  • Unstable angina

In addition to the patient having a critical condition, in order to bill for critical care time, you need to have spent 30 minutes or more on patient care .  This includes time spent on direct patient care, as well as time spent on indirect patient care.  Indirect patient care may include documentation, reviewing prior records, and speaking with consultants, paramedics, and family members.  It is important to note that critical care time does not include time spent on procedures that are billed separately, such as intubations and central lines.

Some critically-ill patients may not qualify for critical care billing .  If a patient with a STEMI is brought in by ambulance and then whisked off to the cath lab within 10 minutes of arrival, they would typically not qualify for critical care billing, regardless of how unstable they were.  At least 30 minutes of time must be spent on patient care to bill for critical care.

If you care for a patient who meets the criteria for critical care billing and document it as such, these CPT codes ( 99291 for the first 30-74 minutes, 99292 for each additional 30 minutes beyond the first 74 minutes) supercede all of the elements discussed above for coding a E/M level 5 chart.  Meaning, if you didn’t document a social history and your ROS only includes 8 organ systems instead of the 10 required for a level 5 chart, it will still be billed as a critical care chart.

Keep in mind that some patients may appear clinically stable but still qualify for critical care billing.  The hyperkalemic patient who requires treatment, monitoring and frequent reassessments may qualify. As may the asthmatic who requires BiPAP and frequent reassessments.  

Congrats on making it to the end!  I hope this has been helpful. If you have any feedback for me regarding this article please contact me at [email protected] .

Disclaimer: This article was written for informational purposes only.  I cannot guarantee the accuracy of the information provided. Payment policies can vary from payer to payer.  I assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of, or relating to, the use, non-use, interpretation of, or reliance on information contained here.  Specific coding or payment related issues should be directed to the payer.

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99284 Emergency Care - Level 4

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Hospital clinic and office visit charges and medicare payments 2020.

Find Hospital Clinic and Office Visit charges (average price) for 2020, and the payments that Medicare made. Find average charges for about 13,000 different codes (depending whether office or hospital facility-based). National average prices are in a large dataset file. Extremely difficult to use, even if somewhat familiar with using Excel files. File uses HCPCS codes. The most common codes were office visits 99213 (average charge about $149) and 99214 (average charge about $222). Medicare allowed about $72 for code 99213 and about $105 for 99214. Therapeutic exercise (code 97110) had average charge of $63, with Medicare allowing about $26. Lab tests, x-ray, emergency department visits are in the file. An Emergency Department visit (code 99285) had a national average facility charge of $1,201, with Medicare allowing just $174 for the ER visit facility charge. A CBC lab test 85025 had an average charge of $35 (Medicare allowed $8); a blood test coded 88053 had an average charge of $56, with Medicare allowing $10. State by state average prices are also listed. Physician charges may be available in the Provider dataset. Calendar year 2020 data from CMS updated July 2022.

Average Cost of a Hospital ER Visit, MEPS

What is the average cost of a hospital ER visit?  According to the Medical Expenditure Panel Survey (MEPS), the average cost of an ER visit was $1,150 in 2020, up 6.3% from 2019. (If you add medical inflation to 2022, the ER cost estimate would be about $1,210.) Adults ages 18 to 64 had the highest average visit cost at $1,385. Infants and children under age 18 cost $821 per visit on average. Age 65+ averaged $849. The average ER visit cost for someone uninsured was about $1,500 in 2020, up 23% compared to a year earlier. Someone under age 65 with private insurance had an average ER visit expense of $1,682. Many people made more than one trip to the Emergency Room in 2020. Consequently, the total expenditure per person with one or more ER visits during the year, was $1,724 in 2020. The median expenditure per person with an expense was $852.

The costs reported by MEPS are the expenditures (total amounts paid by all parties including insurance) for the ER visits. Actual charges would be much higher. An older, but detailed explanation – using cost to charge ratios – was published in December 2020 ( HCUP Statistical Brief #268 ). It reports an average cost (different methodology) for an Emergency Department visit in 2017 of only $530 (which would be about $609 in 2022 dollars). The federal government has not released costs for the 2021 Emergency Department visits yet. The interactive tool may be difficult for many people to use.

California – Average Inpatient and Outpatient Prices, 2022 Hospital Chargemaster

California provides average prices for inpatient and outpatient procedures as of June 1, 2022, as listed in each hospital’s chargemaster. All CA hospitals are included. Excel files show prices for at least 25 common outpatient procedures. ER visits, MRI and CT test prices should be included, along with selected outpatient surgery. The average cost (charge) for top 25 types of outpatient procedures or surgery includes CPT codes. Outpatient reports may show hospital prices for Emergency Room visits, office visit code 99213, lab tests, CT, MRI, Mammogram, x-ray, ultrasound, Physical Therapy visit, Arthroscopy, colonoscopy, endoscopy, carpal tunnel, hernia repair, gall bladder removal (laparoscopic cholecystectomy), lumbar injections, tonsillectomy, ear tubes and more, depending on each hospital’s highest volume.

California 2022 inpatient prices are listed only in each hospital’s massive and complicated Charge Master, which shows the charge for every pill, lab test and hospital room rate. This is where you will find maternity, obstetrics, newborn nursery, labor and delivery charges. But you may need to wade through more than 10,000 individual services listed in the chargemaster to find what you want to know.  Files are in Excel file format. Prices are from 2022. Consumers can see one hospital at a time by downloading their chargemaster file.  Provided through California OSHPD, the state government Office of Statewide Health Planning and Development.

Colorado Average Cost for Office Visit, ER Visit, Outpatient Tests and Hospital Stay

Find out the average charge and average amounts allowed (cost) for an office visit, ER visit, outpatient tests and hospital stays in Colorado. More than 60 types of hospitalizations and almost 90 outpatient types are listed. Web site shows average price and amount paid in 2020 for each major insurance company. Compare the 9 regions such as Denver, Boulder, Ft. Collins, East CO, etc. Average cost for a 15-minute office visit (code 99213) was $101 in CO in 2020, compared to an average charge of $199. A new patient visit (99203) cost $176 for 30 minutes; the average charge was $288.  The most common type of ER (emergency room department) visit cost $1,293 (allowed) compared to $2,432 in charges. The ER visit code was 99283. The next two most common ER visit types cost $2,202 and $3,586 on average; their charges averaged almost $4,800 and $6,600 respectively. Most likely there were additional tests and imaging charges that were added to the bill.

Almost 13,000 Medicare Advantage cataract and lens procedures were done in 2020 (code 66984). While the average cataract removal charge was over $4,400, the allowed amount was $1,053. The Medicare member was responsible to pay $105 to $227, depending on insurance company. For other insurance, the member might have to pay $943 for a cataract removal. View prices and average costs for colonoscopy and ambulatory knee arthroscopy surgery. Inpatient costs include maternity and newborn charges, C-Section delivery, psychiatric admission, alcohol treatment, rehab, depression, diabetes and many more hospital stays. Consumers may wish to add medical inflation of at least 4.4% for 2022. Provided by the State of Colorado.

Emergency Dept. Report – Florida 2018 prices (pdf)

Find average prices for an Emergency Department visit in Florida in this report. Summary report shows average cost (charges) in 2018 for a hospital ER visit based on acuity. Low acuity Pediatric visit for under age 10 cost about $1,100 in 2018. The more common high acuity pediatric ER visit (through age 17) had an average cost of $3,655, up almost 7% from the prior year. For adults, a high acuity average 2018 charge was $8,164. Common symptoms average cost shown, e.g. $10,506 adults for abdominal pain visit to the ER; $6,215 for back pain; $5,167 for a sprain; $5,450 for a superficial injury/contusion; $2,772 for upper respiratory infection visit; $5,287 for adult pregnancy complication; adult urinary tract infection averaged $7,598. Average pediatric visit for upper respiratory infection cost $2,114. Self-pay uninsured average charge was $1,201 for a low acuity visit, to $6,736 for high acuity. Medical inflation has been more than 13% since 2018, and should be considered in estimating 2023 prices. 26 pages, published by FL Agency for Health Care Admin. This is the latest available report as of July 2023, and it appears Florida has no plans to update the Emergency Department reports.

Florida ER Visit Charges, 2019

Florida ER visit charges for each hospital in 2019. Find the average cost of an emergency room (ER / ED) visit at each Florida hospital in 2019. State average ER visit cost (charge) was $7,321 (about $68 Billion for over 9.2 million ED visits). Average cost was up about 10.8% from 2018. HCA Fawcett Memorial Hospital in Port Charlotte had the highest average charge in FL again in 2019, at a whopping $17,330 per ER visit in 2019. Their average price went up 12.6%. Three additional hospitals had average charges over $16,000: HCA Mercy Hospital a campus of Plantation General Hospital, HCA North Florida Regional Medical Center in Gainesville, and HCA Regional Medical Center Bayonet Point – the same as in 2018. All of the most expensive (average charges) for ED visits are for-profit hospitals. Only 4 hospitals in Florida had an average charge of $1,500 or less. The least cost was Madison County Memorial Hospital in Madison, with an average ER visit cost of just under $1,200.  Number of ER patient visits are shown here. The highest volume Emergency Department was Lakeland Regional Medical Center, with 172,000 visits. Its average price was $7,815.  They are not-for-profit. Complexity and seriousness of the visit vary from hospital to hospital. Easy to use tool, but not severity-adjusted. Average charges for broad diagnostic groups can be found, by using the filters in the search tool. From FloridaHealthFinder.gov.  Check our listing for Hospital Compare to see each hospital’s most recent star ratings and performance on emergency care. The site defaults to 2018 costs, so make sure you check the 2019 box to see the latest. No updates as of March 2023 for 2020, 2021 or 2022 costs of an ER visit. Medical price inflation has gone up about 10.4% since 2019.

Healthcare Expenses for Seniors (MEPS)

Healthcare expenses for seniors are outlined in this MEPS report on Health Care Expenditures for the Elderly Age 65 and over. Median annual expenditures were $4,206 per person (about $5,724 in 2022 dollars). Average annual expenses for those with expense were $9,863 in 2011. Using medical inflation rates, $9,863 is about $13,424 in 2022 dollars. Medicare paid over 62% (up considerably from 10 years earlier); private insurance paid 16%; out-of-pocket amount declined to 12%. 96% of seniors had some healthcare expense, most often office-based care and prescribed medicines. Medications took up 22% of the total, averaging $76 per purchase. For seniors, the inpatient room rate averaged $3,199 per day (sticker shock, and nearly $4,354 in 2022 dollars); ER visit was $884 on average ($1,203 in 2022 dollars); office visit was $228. MEPS Statistical Brief #429 uses 2011 data, published Jan. 2014. Add about 36% to account for medical inflation to 2022.

How Much Does an Office Visit cost compared to an ER visit?

An average physician office visit in 2021 cost $365, compared to $1,164 for an Emergency Room visit. Average expenses went up 9% last year for a physician office visit, and are $100 higher than five years ago. Costs for an ER visit were up 1.2% over last year, and about $160 more than five years ago. Consumers should expect higher costs for 2023 and 2024; $365 in 2021 is about $381 in 2023 using medical inflation factors. With inflation, $1,164 is about $1,215 in 2023 dollars.

MEDIAN expenditure per PERSON with an expense was $513 for office visits and $834 for ER visits. The median expenditures cover the total for the year, including multiple visits. The data from MEPS (Medical Expenditure Panel Survey) informs consumers about the large difference between cost of care in a doctor’s office vs. Emergency Dept, more than 3 times higher. The main link for ER cost and office visit is to the interactive database.

Separately, the most recent MEPS Statistical Brief #517 analyzed Expenses for Office-Based Physician Visits by Specialty and Insurance Type, 2016 . published in October 2018. It is mentioned here only for reference because it shows primary care visit cost $186 in 2016; pediatrics office visit cost $169; ophthalmology visit $307 and OB-GYN visit $280 (all 2016 dollars).

Nevada Hospital Inpatient, ER and Ambulatory Surgery 2022 Average Charges Editor's Pick

Find average hospital, ER, and ambulatory surgery charges in Nevada for 2022. Each hospital is listed by name. Nevada Compare Care shows average hospital charges (prices) for every NV inpatient DRG (Diagnosis Related Group), and overall average ER or ambulatory surgery charge. Overall Nevada 3rd quarter 2022 inpatient charge was a whopping $114,693 per stay, or $20,747 per day. Sample DRGs: Psychoses (average $24,696), Normal Newborn ($6,593), uncomplicated vaginal delivery ($32,945), Septicemia ($175,082 for DRG 871), Major hip or knee replacement ($163,524), Cesarean Section ($53,581 without complications).

The number of ER visits in Nevada during full year 2021 was more than one million. Average 3rd quarter 2022 NV emergency room visit charge was $11,214 statewide. Average ER charges ranged from $2,302 average at Banner Churchill Hospital, to $17,936 average at St. Rose Dominican Siena hospital. Statewide average Ambulatory Surgery Center charge was $8,666. No breakout by procedure type is shown. Endoscopy Center average charges are included. Outpatient surgery at a hospital averaged $55,801 in charges. Standard Reports also show case volume by facility. No information about how much was actually paid. NV reports are a joint effort between Center for Health Information Analysis (CHIA) and the Division of Health Care Financing and Policy (DHCFP).

Vermont – Compare Hospital ER Prices (2022) Editor's Pick

Compare published prices for hospital Emergency Room visits, for all 14 hospitals in VT, according to level of severity and complexity. Statewide average ER price from Oct. 1 2021 to Sept. 30, 2022 is $433 for Level 1 minor problem, before adding tests or procedures. The price has risen an average of 9% per year since 2019. Very few visits are this “simple”. Level 2 low severity ER visit average price was $591 before adding test costs. Level 3 moderate severity and complexity ER visit (the most common in the US) average price is $990 for hospital and physician charges, excluding tests and medications etc. Both Level 2 and Level 3 average prices for an ER visit rose about 6% per year over the past 3 years. Level 4 average price is $1,490.  Top base price for a Level 5 visit was $2,097 per visit ($1,546 hospital, $551 doctor fee). Level 4 and Level 5 Emergency Department visits have risen about 5% per year, over the past 3 years in Vermont.

For consumer planning purposes, billing code Levels 3, 4 and 5 are most likely to occur. A recent study of Medicare patients found that the most common ER visit charge was for a Level 5 visit, right at the top of the complexity scale. Both facility and physician charges are shown – an amazing show of leadership in price transparency. Springfield Hospital’s Level 5 charge is $1,441; the University of Vermont Medical Center’s Level 5 ER charge is over $3,000. Prices do NOT include lab tests, imaging tests or procedures during the ER visit. Prices are good from October 2021 through September 30, 2022. Table 3D published in 2022. Editor’s Pick because VT got this report out while the published prices were still in effect – if even for only a few months.

Virginia Healthcare Prices – ER Visit, Ambulatory Surgery, Test, Hospital Stay Costs

Find Virginia Healthcare Prices for ER visits, ambulatory surgery, tests and hospital stays. This site shows average price ALLOWED (commercial insurance prices) in 2018 for almost 40 common healthcare services in VA. Includes a mix of outpatient, clinic, hospital stays and other services such as an ambulance (median $550) or an emergency helicopter ride ($19,466 which includes average base cost of $14,402 plus mileage). Examples: hospitalizations (maternity), outpatient xray/imaging, CT and MRI tests; colonoscopy, mammogram; inpatient or ambulatory surgery (e.g. hernia, gall bladder, knee replacement, tonsillectomy, kidney stones); and ER or well-child visits (median $126). Shows median and range of costs and provides a breakout by type of cost: facility, surgeon, anesthesiologist, etc. Also shows average price by setting: clinic vs. hospital vs. ambulatory surgical center; and region of Virginia. The median amount allowed for an ER visit (medium, code 99283) was $1,091. The 2020 report shows allowed amounts for each service that you or your insurance plan ACTUALLY PAID in 2018. More relevant than most pricing information, but lags in timeliness. Add at least 12% medical inflation rate to estimate 2022 costs. Virginia Healthcare Pricing Transparency, from Virginia Health Information (VHI), updated June 2020. No new updates as of August, 2022.

Wisconsin ER Hospital Prices (Emergency Department)

Find 2022 ER visit prices to WI hospital emergency departments (ER). Shows median (middle) price for ER (2022) WITHOUT the physician’s fee. It also shows how many cases the hospital treated. Must know how complex the visit is, or use the CPT code. The most common is “high level” of medical decision-making (CPT 99285). Statewide, hospitals charged $2,150 (median charge during 2022) for ER visit 99285. While the tool is slow and cumbersome, Wisconsin Hospital Association’s PricePoint makes comparing hospital prices possible. This site is one of the more up to date sites for healthcare price transparency. Compare hospitals downtown vs. those in the suburbs. Updated 2023. Urgent care prices do not appear to be included any longer, nor are 50 services within Emergency Department visits. Sample median cost for two levels of ER visits:

Nevada Hospital Emergency Room Prices – Compare (free)

Compare Nevada hospital ER visit prices (2021) for common reasons people visit emergency departments. Choose illness and hospital (one hospital at a time). Compare to common charges in the county and NV average. For example, a migraine treated in ER typically cost $7,141 in NV. (Note, the median charge went up 20% per year since 2014, for migraines treated in the ER.) Consumers should also note that physician fees are extra, and NOT shown in the website prices. They may also need to add inflation factors. Prices are disease-specific. Nevada PricePoint through NV Hospital Association.

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  • Center on Health Equity and Access
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A Revised Classification Algorithm for Assessing Emergency Department Visit Severity of Populations

  • Debra M. Ravert, MD
  • Jonathan P. Weiner, DrPH

An updated emergency visit classification tool enables managers to make valid inferences about levels of appropriateness of emergency department utilization and healthcare needs within a population.

ABSTRACT Objectives: Analyses of emergency department (ED) use require visit classification algorithms based on administrative data. Our objectives were to present an expanded and revised version of an existing algorithm and to use this tool to characterize patterns of ED use across US hospitals and within a large sample of health plan enrollees.

Study Design: Observational study using National Hospital Ambulatory Medical Care Survey ED public use files and hospital billing data for a health plan cohort.

Methods: Our Johns Hopkins University (JHU) team classified many uncategorized diagnosis codes into existing New York University Emergency Department Algorithm (NYU-EDA) categories and added 3 severity levels to the injury category. We termed this new algorithm the NYU/JHU-EDA. We then compared visit distributions across these 2 algorithms and 2 other previous revised versions of the NYU-EDA using our 2 data sources.

Results: Applying the newly developed NYU/JHU-EDA, we classified 99% of visits. Based on our analyses, it is evident that an even greater number of US ED visits than categorized by the NYU-EDA are nonemergent. For the first time, we provide a more complete picture of the level of severity among patients treated for injuries within US hospital EDs, with about 86% of such visits being nonsevere. Also, both the original and updated classification tools suggest that, of the 38% of ED visits that are clinically emergent, the majority either do not require ED resources or could have been avoided with better primary care.

Conclusions: The updated NYU/JHU-EDA taxonomy appears to offer cogent retrospective inferences about population-level ED utilization.

Am J Manag Care. 2020;26(3):119-125. https://doi.org/10.37765/ajmc.2020.42636

Takeaway Points

  • There is renewed interest in understanding emergency department (ED) use patterns in populations, both because of increased use associated with healthcare reform and as private payers seek to stem their rising ED spending.
  • To assess the appropriateness of ED use at the population level, validated classification methods that use available administrative data will be required.
  • Our analysis using an updated classification suggests that an even greater number of ED visits than previously categorized are nonemergent.
  • Health plans and other organizations might use ED visit classification algorithms to gain an understanding about how populations make use of hospital services.

The New York University Emergency Department Algorithm (NYU-EDA) is widely used to classify emergency department (ED) visits. 1,2 This measurement tool’s development occurred in the late 1990s and was based on 5700 ED discharge abstracts from 6 hospitals in the Bronx, a borough of New York City. The NYU-EDA probabilistically classified 659 diagnosis codes from the International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ). The original NYU-EDA mapped only about 5% of all ICD-9-CM diagnosis codes. We propose an algorithm that remedies this shortfall and classifies nearly all ED visits.

The NYU-EDA has been applied in health services research studies to identify emergent visits that required ED care. 3,4 Several studies have focused on nonemergent and primary care—treatable ED visits and evaluated emergent and nonemergent utilization patterns to assess the impact of healthcare reforms. 5-11 Estimates of proportions of nonemergent visits have ranged between 17% and 49%. One study looked at primary care—sensitive (PCS) visits (ie, emergent visits that are potentially avoidable and nonemergent and primary care–treatable visits) and found that up to 50% of ED visits were PCS in a statewide all-payer claims database with 92% of ED visits classified. 12

Evidence for the validity of the NYU-EDA has grown over 2 decades. Emergent visits were associated with total charges and increased likelihood of death and inpatient hospitalization directly from the ED and within 30 days from a previous visit. 10,13-15 However, researchers and emergency medicine clinicians have cautioned against using visit classifications based solely on discharge diagnoses for interventions aimed at reducing unnecessary visits or for denying payment. First, underlying differences in morbidity and access to care may, to some degree, account for utilization patterns that would be detected by an ED visit classification algorithm. Second, there are reasons for visits on the individual level that may be appropriate for ED utilization, which can differ from discharge diagnoses that categorize the encounter as nonemergent. For example, patients who are experiencing chest pain and come to the ED for evaluation are not necessarily inappropriately using the ED. ED visit classifications are useful tools for understanding the healthcare needs of populations, not the medical needs of individual patients. 16-19

A team of Johns Hopkins University (JHU) emergency medicine physicians and health services researchers has further updated and expanded the NYU-EDA using their best clinical judgment and diagnosis aggregations from the Adjusted Clinical Groups (ACG) System. 20 In this revised JHU version of the NYU-EDA (or NYU/JHU-EDA for short) we undertook 3 significant modifications and improvements to the original version and updates undertaken by other teams. First, rather than assigning ICD codes probabilistically, we classify each ED visit into 1 of 11 categories. Second, rather than placing all injuries into 1 category, we subcategorize injuries into 3 severity levels: nonsevere injuries, severe injuries, and severe injuries that are likely to require inpatient admissions. Third, we significantly expand the classification of ICD codes.

In this article, we describe the updated NYU/JHU-EDA, and, using data from a federal survey of US hospital EDs and a large claims database from multiple health plans, we compare results of our revised tool with the original NYU-EDA and 2 earlier modifications developed by Johnston et al and Ballard et al. 2,13

The first objective of this article is to offer a description and first-stage assessment of our ED classification algorithm. The second goal is to use this methodology to offer an account of use patterns of American EDs based on a representative sample of patients visiting hospital EDs and a large national sample of health plan enrollees. In addition to describing our new measurement tool, our analysis adds to the literature on how Americans use EDs and will offer insights into how health plans and other organizations might use classification algorithms to gain an understanding of how populations make use of hospital EDs.

Review of Previous Approaches for Classifying ED Visits

The original NYU-EDA first classifies common primary ED discharge diagnoses as having varying probabilities of falling into each of the 4 following categories: (1) nonemergent; (2) emergent, primary care treatable; (3) emergent, ED care needed, and preventable or avoidable with timely and effective ambulatory care; and (4) emergent, ED care needed, and not preventable. 1 The original NYU system categorizes certain diagnoses separately and directly into 5 additional categories: injuries, psychiatric conditions, alcohol related, drug related, or unclassified.

The adaptation by Ballard et al sums the NYU-EDA probabilities for nonemergent and emergent primary care—treatable visits and compares this sum with the total probability of the emergent, ED care needed categories. 13 Depending on the larger of the 2 resultant likelihoods, visits are classified as nonemergent or emergent, or as intermediate when there is an equal probability of being nonemergent or emergent. The Ballard et al method classifies visits into 1 of 8 categories, which have been shown to be a good predictor of subsequent hospitalization and death within 30 days of an ED visit. 13

After 2001, the NYU-EDA was not updated, and newly added diagnosis codes were not classified. In 2018, Johnston and colleagues identified new codes that are “nested” within previously classified diagnoses and applied the original probabilistic weights to these codes. 2 New diagnoses that remained unclassified were “bridged” to already weighted codes using ICD -based condition groupings from the Agency for Healthcare Research and Quality Clinical Classification System. 21 Instances in which a new diagnosis mapped to several codes with different weights were resolved in favor of a code most likely to represent an unavoidable emergent visit. 2 Because assigned weights sum to 1, both the original NYU-EDA and the update by Johnston et al describe a collection of ED visits by averaging weights.

We took a different approach to update, enhance, and expand the NYU-EDA method. We did not use probabilities but rather assigned primary discharge diagnoses to single classes and uniquely classified each ED visit. For codes that had been previously included in the original NYU-EDA, we based our updated assignments on the category with the highest probability. We resolved cases of equally high probabilities among multiple categories by giving preference to the emergent, ED care needed category.

Data Sources

To build our revised methodology, we combined ED encounter data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from the period of 2009 to 2013. We used data from the 2014 survey for validation. 22 The reason for an ED visit is present in NHAMCS data and contained mainly signs and symptom diagnoses, but it was not present in claims. We used discharge diagnoses only and thus retained a key characteristic of the NYU-EDA and previous revised versions. Second, we extracted hospital ED claims from a large health insurance plan database. We obtained health plan claims data from QuintilesIMS (Plymouth Meeting, Pennsylvania [on November 6, 2017, the name of the organization changed to IQVIA]). The claims extract spanned the same time period (2009-2013) and included 14 commercial health plans; 6 of these plans also had Medicaid and Medicare managed care enrollees. The database consisted of patient enrollment data, ICD-9-CM diagnoses, hospital revenue center codes, procedures coded with Current Procedural Terminology (CPT), and plan-allowed amounts for medical services.

Following the literature, we identified ED visits in the claims database through the presence of revenue center codes (0450-0459, 0981) and CPT codes for evaluation and management (EM) services in the ED (99281-99285). 23,24 We resolved instances in which facility and professional claims indicated different primary diagnoses by prioritizing facility bills. Our rationale for giving diagnoses on facility bills priority over professional bills for the same visit is that facility bills relate more closely to the final discharge record, whereas some professional claims may contain preliminary diagnoses.

Development of the NYU/JHU EDA

We applied the Johns Hopkins ACG system to help categorize diagnoses that were not included in the original NYU-EDA method. The system assigns diagnoses found in claims or encounter data to 1 of 32 Aggregated Diagnosis Groups (ADGs) (ie, morbidity types with similar expected need for healthcare resources). 25,26 The ACG system also maps diagnoses to 1 of 282 Expanded Diagnosis Clusters (EDCs) (ie, clinically homogeneous groups of diagnoses).

To help expand the scope of the NYU-EDA visit classification to more diagnoses, we formed “clinical classification cells” for ICD codes falling within combinations of ADGs and EDC clusters. Each unique cell was reviewed and categorized by our clinician team of 3 practicing emergency physicians (K.P., D.M.R, and Dr Alan Hsu).

For classification cells with ICD codes that were not previously classified with NYU-assigned probabilities, 2 of our clinicians independently assigned an ED visit class. After differences among approximately 35% of all manual assignments were reconciled and finalized by the third clinician, we developed majority class assignments for the remaining diagnoses within classification cells. Relatively uncommon diagnoses within cells that contained only codes without any original NYU-EDA weights or any manually assigned diagnosis remained unclassified. Using this approach, our NYU/JHU-EDA currently classifies 10,723 ICD-9-CM and 74,329 International Classification of Diseases, Tenth Revision, Clinical Modification ( ICD-10-CM ) codes ( eAppendix Tables 1 and 2 [ eAppendix available at ajmc.com ] provide examples of common ICD codes in each NYU/JHU-EDA category).

To help us assign severity levels to ACG-based classification cells consisting of injury-related diagnoses, we used CPT codes for EM services associated with ED visits and further assessed whether visits resulted in an inpatient admission. EM codes classify severity from minor (99281) to high with immediate threat to life or physiologic function (99285). We counted the number of nonsevere injury visits (99281-99283) and the number of severe injury visits (99284, 99285) in our health insurance claims data sets. Based on the larger of the 2 counts, each of our injury diagnosis clusters was classified as being either nonsevere or severe. A subset of severe injury visits was identified as likely to require inpatient hospitalization based on a greater than 50% likelihood of cases being admitted. All injury ICD clusters that were so assigned into 1 of 3 severity levels underwent a final clinical review by our clinician team. A graphic overview of the final classification categories of our revised NYU/JHU-EDA grouping taxonomy is presented in the Figure .

Statistical Analysis

We conducted pairwise comparisons of visit distributions among the 4 EDA versions applied to NHAMCS and health plan data and computed Cramér’s V measure of association. Cramér’s V is a number between 0 and 1 that indicates how strongly 2 categorical variables are associated. It is based on Pearson’s χ 2 statistic and computed as follows:

level 4 er visit meaning

Download PDF: A Revised Classification Algorithm for Assessing Emergency Department Visit Severity of Populations

level 4 er visit meaning

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Follow these four steps to code quickly and accurately, while reducing the need to count up data points.

KEITH W. MILLETTE, MD, FAAFP, RPh

Fam Pract Manag. 2021;28(4):21-26

Author disclosure: no relevant financial affiliations.

level 4 er visit meaning

The new rules for coding evaluation and management (E/M) office visits are a big improvement but still a lot to digest. 1 , 2 To ease the transition, previous FPM articles have laid out the new American Medical Association/CPT medical decision making guide 3 and introduced doctor–friendly coding templates (see “ Countdown to the E/M Coding Changes ,” FPM , September/October 2020), explained how to quickly identify level 4 office visits (see “ Coding Level 4 Visits Using the New E/M Guidelines ,” FPM , January/February 2021), and applied the new guidelines to common visit types (see “ The 2021 Office Visit Coding Changes: Putting the Pieces Together ,” FPM , November/December 2020).

After several months of using the new coding rules, it has become clear that the most difficult chore of coding office visits now is assessing data to determine the level of medical decision making (MDM). Analyzing each note for data points can be time-consuming and sometimes confusing.

That being the case, it's important to understand when you can avoid using data for coding, and when you can't. I've developed a four-step process for this (see “ A step-by-step timesaver ”).

The goal of this article is to clarify the new coding rules and terminology and to explain this step-by-step approach to help clinicians code office visits more quickly, confidently, and correctly.

The new evaluation and management office visit coding rules have simplified many things but are still a lot to digest, especially when it comes to counting data.

There are different levels of data and different categories within each level, which can make using data to calculate the visit level time-consuming and confusing.

By calculating total time, and then moving on to assessing problems and prescription drug management, most visits can be optimally coded without dealing with data at all.

OFFICE VISIT CODING RULES AND TERMINOLOGY

To make full use of the step-by-step process, we have to first understand the new rules, as well as coding terminology. Here is a brief summary.

Medically appropriate . Physicians and other qualified health care professionals may now solely use either total time or MDM to determine the level of service of an office visit. That means the “history” and “physical exam” components are no longer needed for code selection, which simplifies things. But your patient note must still contain a “medically appropriate” history and physical. So continue to document what is needed for good medical care.

New patient . A new patient is a patient who has not been seen by you or one of your partners in the same medical specialty and the same group practice within the past three years.

Total time and prolonged services . Total time includes all the time you spend on a visit on the day of the encounter (before midnight). It includes your time before the visit reviewing the chart, your face-to-face time with the patient, and the time you spend after the visit finishing documentation, ordering or reviewing studies, refilling medications, making phone calls related to the visit, etc. It does not include your time spent performing separately billed services such as wellness visits or procedures. Total time visit level thresholds differ for new patients vs. established patients. (See the total times in “ The Rosetta Stone four-step template for coding office visits .”)

The prolonged services code comes into play when total time exceeds the limits set for level 5 visits by at least 15 minutes.

Medical decision making . MDM is made up of three components: problems, data, and risk. Each component has different levels, which correspond to levels of service (low/limited = level 3, moderate = level 4, and high/extensive = level 5). The highest level reached by at least two out of the three components determines the correct code for the level of service. MDM criteria is the same for new and established patients.

Problems addressed . This includes only the problems you address at that specific patient visit. It does not include all the patient's diagnoses and does not include problems that are exclusively managed by another clinician. Problems addressed are separated into low-complexity problems (level 3), moderate-complexity problems (level 4), and high-complexity problems (level 5). To code correctly, you need to know the coding value of the problems you address. It is helpful to think of problems in terms of levels of service (e.g., a sinus infection is usually a level 3 problem, and pneumonia or uncontrolled diabetes are usually level 4 problems).

The simplest way to summarize problems is this: Life-threatening problems are level 5; acute or chronic illnesses or injuries are level 3 or 4 depending on how many there are, how stable they are, and how complex they are; and if there's just one minor problem, it's level 2.

(For more specifics see “ What level of problem did I address? ”)

Risk . Risk is also separated into “low” (level 3), “moderate” (level 4), and “high” (level 5) categories.

Level 3 risk includes the use of over-the-counter (OTC) medications.

Level 4 risk includes the following:

Prescription drug management: starting, stopping, modifying, refilling, or deciding to continue a prescription medication (and documenting your thought process),

Social determinants of health that limit diagnosis or treatment (this is when patients' lack of finances, insurance, food, housing, etc., affects your ability to diagnose, manage, and care for them as you normally would).

Level 5 risk includes the following:

Decisions about hospitalization,

Decisions about emergency major surgery,

Drug therapy that requires intensive toxicity monitoring,

Decisions to not resuscitate or to de-escalate care because of poor prognosis.

Data analyzed . For purposes of MDM, data is characterized as “limited” (level 3 data), “moderate” (level 4 data), or “extensive” (level 5 data). But each level of data is further split into Categories 1, 2, and 3. This can make calculating data complicated, confusing, and time-consuming. Here are the data components and terms you need to know.

Category 1 data includes the following:

The ordering or reviewing of each unique test , i.e., a single lab test, panel, X-ray, electrocardiogram (ECG), or other study.

Ordering and reviewing the same lab test or study is worth one point, not two; a lab panel (e.g., complete blood count or comprehensive metabolic panel) is worth one point,

Reviewing a pertinent test or study done in the past at your own facility or another facility,

Reviewing prior external notes from each unique source, including records from a clinician in a different specialty or from a different group practice or facility as well as each separate health organization (e.g., reviewing three notes from the Mayo Clinic is worth one point, not three, but reviewing one note from Mayo and one from Johns Hopkins is worth a total of two points),

Using an independent historian, which means obtaining a history from someone other than the patient, such as a parent, spouse, or group home staff member. (This is included in Category 2 for level 3 data, but falls into Category 1 for level 4 and 5 data.)

Category 2 data includes the following:

Using an independent historian (for level 3 data only),

Independent interpretation of tests, which is your evaluation or reading of an X-ray, ECG, or other study (e.g., “I personally reviewed the X-ray and it shows …”) and can include your personal evaluation of a pertinent study done in the past at your or another facility. It does not include reviewing another clinician's written report only, and it does not include studies for which you are also billing separately for your reading.

Category 3 data includes the following:

Discussion of patient management or test interpretation with an external physician, other qualified health care professional, or appropriate source. An external physician or other qualified health care professional is someone who is not in your same group practice or specialty. Other appropriate sources could include, for example, consulting a patient's teacher about the patient's attention deficit hyperactivity disorder.

A STEP-BY-STEP TIMESAVER

The majority of office visits can be optimally coded by using time or by looking at what level of problems were addressed (see Steps 1 and 2 below) and whether a prescription medication was involved.

A level 3 problem can be coded as a level 3 visit if you address it with an OTC or prescription medication. A level 4 problem can be coded as a level 4 visit if you order prescription medication or perform any other type of prescription drug management (modifying, stopping, or deciding to continue a medication). Most level 2 and level 5 office visits are straightforward, and most level 5 visits will be coded by time. They will typically be visits in which you address multiple problems or complicated problems and the total time exceeds 40 minutes for established patients. This is much more common than seeing critically ill patients who may require admission, which is another level 5 scenario. The few remaining patient visits that have not already been coded require analyzing data (Steps 3 and 4). (See “ The Rosetta Stone four-step template for coding office visits .”)

Step 1: Total time . Think time first. If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if it does not, go to Step 2.

Step 2: “Problems plus.” Don't be afraid to move on from time-based coding if you believe you performed a higher level visit using MDM. Many visits can be coded with MDM just by answering these two questions: What was the highest-level problem you addressed during the office visit? And did you order, stop, modify, or decide to continue a prescription medication?

If you addressed a level 2 problem and your total time was less than 20 minutes (or less than 30 for a new patient), then code level 2.

If you addressed a level 3 problem, plus you recommended an OTC medication or performed prescription drug management, then code level 3.

If you addressed a level 4 problem, plus you performed prescription drug management, then code level 4.

Chronic disease management often qualifies as level 4 work. For documentation, think “P-S-R”: problem addressed, status of the problem (stable vs. unstable), and prescription drug management (Rx). This trio should make it clear to coders, insurance companies, and auditors that level 4 work was performed.

For instance, if a patient has controlled hypertension and diabetes and you document that you decided to continue the current doses of losartan and metformin, that's level 4 (two stable chronic illnesses plus prescription drug management). If you see a patient with even one unstable chronic illness and document prescription drug management to address it, that's also level 4.

For a level 5 problem, if you see a really sick patient and decide to admit or consider admission (and you document your thought process in your note), then code level 5.

By starting with total time and, if necessary, moving on to “problems plus,” you will probably be able to optimally code 90% of your office E/M visits. But on the rare occasions when you see a patient for level 4 or 5 problems for less than the required time and don't do any prescription drug management, you may have to proceed to Steps 3 and 4.

Step 3: Level 4 problem with simple data or social determinants of health concerns . Code level 4 if you saw a patient for a level 4 problem and did any of the following:

Personally interpret a study (e.g., X-ray),

Discuss management or a test with an external physician,

Modify your workup or treatment because of social determinants of health.

Step 4: Level 4 or 5 problem with complex data . If you saw a patient for a level 4 problem and still haven't been able to code the visit at this point, you have to tally Category 1 data points:

Review/order of each unique test equals one point each,

Review of external notes from each unique source equals one point each,

Use of an independent historian equals one point.

Once you reach three points, code it as level 4.

For a level 5 problem, if you see a really sick patient, order/interpret an X-ray or ECG, and review/order two lab tests, then code level 5.

Following these steps should allow you to quickly identify the optimal level to code most any E/M office visit (for pre-op visits, see “ Coding pre-ops template .”)

Here's a catchy rhyme to remember the basic outline of the steps:

To finish fast ,

code by time and problems first ,

and save data for last .

By mastering the new coding rules and terminology and applying this four-step approach, you can code office visits more quickly, accurately, and confidently — and then spend more time with your patients and less time at the computer.

CPT Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Code and Guideline Changes . American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

E/M Office Visit Compendium 2021. American Medical Association; 2020.

Table 2 – CPT E/M office revisions level of medical decision making. American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

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Emergency Room Severity Levels

Many ERs assess their patients’ conditions as a severity level from 1 (least severe) to 5 (most severe) at their sole discretion. The ER then bills a ‘facility’ or ‘service’ fee based on their assessed severity level. (This fee is inherently patient-antagonistic. I recommend writing your government representatives and insisting that this ridiculous fee be banned.) ERs generally do not reveal the criteria used for their assessment, but the guidelines are supposed to be standardized. Below are descriptions of the 5 levels. Thanks to Medical Recovery Services LLC ( mrsllc.org ) for providing this information.

Severity Level 1

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor.

Severity Level 2

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity.

Severity Level 3

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity.

Severity Level 4

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.

Severity Level 5

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

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Measuring Emergency Department Acuity

Maame yaa a. b. yiadom.

1 Vanderbilt University, Department of Emergency Medicine, Nashville, TN, USA

Christopher W. Baugh

2 Brigham and Women’s Hospital, Harvard University, Department of Emergency Medicine, Boston, MA, USA

Tyler W. Barrett

3 Vanderbilt University, Department of Biostatistics, Nashville, TN, USA

Alan B. Storrow

Timothy j. vogus.

4 Vanderbilt University, Owen Graduate School of Management, Nashville, TN, USA

Vikram Tiwari

5 Vanderbilt University, Departments of Anesthesia and Bioinformatics, Nashville, TN, USA

Corey M. Slovis

Stephan russ, the ed operations study group 2015.

6 Nashville, TN, USA

Emergency department (ED) acuity is the general level of patient illness, urgency for clinical intervention, and intensity of resource use in an ED environment. The relative strength of commonly used measures of ED acuity is not well understood.

We performed a retrospective cross-sectional analysis of ED-level data to evaluate the relative strength of association between commonly used proxy measures with a full spectrum measure of ED acuity. Common measures included the percentage of patients with Emergency Severity Index (ESI) scores of 1 or 2, case mix index (CMI), academic status, annual ED volume, inpatient admission rate, percentage of Medicare patients, and patients-seen-per-attending-hour. Our reference standard for acuity is the percentage of high acuity charts (PHAC) coded and billed according to the Centers for Medicare and Medicaid Service’s Ambulatory Payment Classification (APC) system. High acuity charts included those APC 4, 5 or critical care. PHAC was represented as a fractional response variable. We examined the strength of associations between common acuity measures and PHAC using Spearman’s rank correlation coefficients (r s ) and regression models including a quasi-binomial generalized linear model and linear regression.

In our univariate analysis, the percentage of patients ESI 1 or 2, CMI, academic status and annual ED volume had statistically significant associations with PHAC. None explained more than 16% of PHAC variation. For regression models including all common acuity measures, academic status was the only variable significantly associated with PHAC.

ESI had the strongest association with PHAC followed by CMI and annual ED volume. Academic status captures variability outside of that explained by ESI, CMI, annual ED volume, percentage Medicare patients, or patients-per-attending-per-hour. All measures combined only explained only 42.6% of PHAC variation.

INTRODUCTION

Emergency department (ED) acuity may be defined as the general level of patient illness, urgency for clinical intervention, and the intensity of resource use within an ED’s clinical care environment. In this context it is a characteristic encompassing the intensity of medical need and services delivered. Validated measures to compare ED acuity, as a cross-institutional measure, are limited despite it being an important metric to guide clinical resource allocation.

Here we explore acuity as a quality of the ED care environment for which comparisons can be made across facilities with 2 specific phenomena in mind. First, is the growing number of metrics making performance comparisons across a diversity of facilities all described as EDs. The function and performance of an ED may be different based on whether it is a relatively lower or higher acuity facility. Being able to identify these differences relies on comprehensively assessing acuity. EDs also range from 5,000 visit per year critical access centers to 250,000 visits per year facilities with care sub-units. Measures need to go beyond size and volume differences to include the diversity of patient care needs, resources available and applied to provide care, and the urgency with which ED care is needed or delivered (i.e. – the balance of primary/urgent care to emergency acute care requiring early involvement of specialist services such as stroke, emergency abdominal surgery, ST-segment elevation myocardial infarction, and impending labor). Second, is the drive to adopt practice innovations (e.g. - split flow, team triage, physician-in-triage, ED physician cath lab activation, chest pain protocols) from one ED to another. Doing so relies on being able to assess the transferability of a practice or policy between EDs. One important consideration is whether the intervention’s performance was tested in an ED of similar overall patient illness, urgent need for clinical intervention, and intensity of resources used for acute care. As a result, it is critical to understand the reliability of measures used to differentiate EDs by their acuity.

Common proxies for ED acuity include: the aggregated Emergency Severity Index (ESI) score, case mix index (CMI), 1 , 2 annual ED volume, 3 , 4 , 5 academic status, 6 and inpatient admission rate (the percentage of ED patients admitted to the hospital with the intensity of care meeting “inpatient” as opposed to intense “observation” level admissions). 6 , 7 In addition, many national benchmarking organizations within emergency medicine use percentage of higher risk ED populations and resource-to-patient ratios. Examples include the percentage of Medicare patients and patients-per-attending-hour. 8 , 9 , 10

Despite the frequent use of these metrics, each has significant limitations in capturing the level of acuity for the full spectrum of an ED’s clinical environment. In this study we assess how commonly used proxies are related to the full spectrum of ED acuity as measured by the percentage of high acuity charts (PHAC). To our knowledge, a study of this kind has not been done in emergency medicine, because obtaining these measures for cross-institutional comparison is challenging. The ED Operations Study Group (EDOSG) is a non-profit research consortium dedicated to advancing research informing evidence-based clinical operations. The organization’s research network has the ability to obtain these measures for a sample of EDs, while representing the diversity of clinical practice in the United States (US). Despite this innovation and opportunity to explore ED acuity, we acknowledge there is no true reference standard. As a result, our analyses should be considered more suggestive than conclusive.

Study Design

This was a retrospective cross-sectional study using ED-level EDOSG data collected via survey as reported by each member ED. The objective was to determine the strength of association between common proxies for ED acuity with a rationalized reference standard, PHAC. Independent variables included seven established proxies for ED acuity including the percentage of patients with an Emergency Severity Index (ESI) score of 1 or 2, CMI, 1 , 2 annual ED volume, 3 , 4 , 5 academic status, 6 inpatient admission rate (the percentage of ED patients admitted to the hospital with the intensity of anticipated care designated as “inpatient” as opposed to “observation”), the percentage of Medicare patients, and patients-seen-per-attending-hour per day.

Study Population

With the ED as the unit of analysis, our study population included 62 facility members of the EDOSG summarizing the care delivered during 3,323,071 ED visits in 2014. The group represents the diversity of US EDs in terms of US geographic regions, infrastructure, patient acuity, patient volume, academic intensity, and clinical staffing differences. ( Table 1 )

Characteristics of Emergency Departments with and without Complete Data 1

a b c represent the lower quartile a , the median b , and the upper quartile c for continuous variables x ± s represents X ± 1 SD.

Data Collection

We asked each site to provide demographic information for their facility, percentage of patients with ESI 1 or 2, CMI 1 , 2 annual ED volume, 3 , 4 , 5 academic status, 6 inpatient admission rate, 6 , 7 percent of patient admitted under observation status, percentage of Medicare patients, patients-seen-per-attending-hour per day, and the aggregated percentage of billed charts falling into each ambulatory payment classification (APC) coding level category. 8 , 9 , 10 Each site PI agreed to accurate data collection and reporting to the EDOSG. Most frequently site-PIs are medical or clinical operations directors. The group, however, includes directors of research, nurse administrators, and research faculty with clinical operations interests. All were individuals with roles permitting data access. The data for this study were collected simultaneously with the EDOSG’s 2015 ED metric collection reflecting 2014 clinical care.

Primary Outcome

Our primary outcome was the PHAC coded and billed within each ED according to the Center for Medicare and Medicaid Service’s APC system as our measure of the acuity within each EDs care environment. Most ED visits are captured in a chart documenting patient symptoms, clinician observations, and medical care provided. The majority are then coded using the APC system. APC coding is a federal scaling system developed to guide Medicare and Medicaid reimbursements according to a hierarchy of patient illness and resources applied for ambulatory care. 9 It consists of a scale of 1–5 where 5 represents a high level of care intensity and patient acuity. 11 Two levels of critical care can replace a level 5 chart if intensive-care unit level services are provided. Higher coding levels result in higher reimbursements for physician evaluation and management professional fees. Charts scored as levels 4, 5, or with associated critical care represent the highest acuity patients. Other payers have since adopted this system for reimbursement.

The US Office of the Inspector General (OIG) monitors fraud and abuse of this classification system, and is empowered to conduct audits when inappropriate billing is suspected. Periodic analyses of national trends are performed to monitor coding shift. Penalties can be applied to the institution for verified misconduct. 11 The APC system was not designed to measure ED acuity. However, the ability of the percentage of high acuity charts to retrospectively account for resource intensity and patient level of illness, and the wide spread use of the standardized and federally monitored APC system, makes it our rationalized reference standard.

We asked each ED to report the percent distribution of their coded and billed charts for 6 ranked categories: levels 1 through 5, and critical care. We then calculated the percentage of high patient acuity charts – levels 4, 5 and critical care – to obtain the PHAC for each ED. EDs with missing PHAC were excluded from the analysis. All unbilled patient charts were excluded, yet represented less than 5% of all ED visits.

Statistical Analysis

We reported data as aggregated counts, means, and percentages for measures of resource utilization, process, and performance. We used descriptive statistics to report summaries as percentages and medians with interquartile ranges (IQR). This is the standard for measuring clinical performance within emergency medicine. 14 However, we simultaneously calculated means with one standard deviation (SD) to identify skewness that would otherwise be masked.

We evaluated associations between common proxies of acuity and PHAC in three ways: rank-based analyses, graphical assessment and regression analyses. First, we examined the strength of association between PHAC and common acuity measures using Spearman’s rho rank correlation coefficients for continuous acuity measures and the Kruskal-Wallis rank sum test for categorical acuity measures. Those rank-based methods avoid distributional assumptions and thus are less influenced by outliers. Second, we used scatterplots with loess smoothed lines or box plots to visualize the relationship of each common acuity measure with PHAC. Lastly, we conducted regression analysis to relate traditional acuity measures separately and combined with PHAC. PHAC ranges between 0 and 1 and represents a proportional quantity represented as a fractional response varable. In addition, we were concerned relationships with PHAC may not be linear. As a result we used a quasi-binomial generalized linear regression models (GLM) with logit link as our primary regression approach. We then repeated the univariate and multivariate analyses using a linear model to compare and assess whether assuming linearity in the measures relationship with PHAC was reasonable. Within both models, the univariate analyses quantified the relationship between each individual common acuity measure and PHAC and the multivariate analyses tested the degree to which the common measures could jointly predict PHAC.

Multiple imputation was used to handle missing common acuity measures to prevent a statistical power reduction and avoid potentially biased results from only including EDs with complete cases. 12 Specifically, missing data for independent variables were imputed 10 times using additive imputation models allowing for nonlinear transformations on the data to make optimal use of partial information recorded for each ED. We then summarize the regression results from all 10 multiple imputations.

Traditional likelihood based goodness of fit statistics such as the Akaike information criterion (AIC) do not apply to quasi-likelihood based GLM. Therefore, R-squared (R 2 ) was used as a goodness-of-fit statistic for model comparisons. For models assessing combined effects of all seven acuity measures (full model), we tested a series of nested models and compared each with the full model using R 2 to avoid over-fit. The nested models excluded 1 or 2 variables explaining the least variance of PHAC. We observed minimal differences in R 2 , the strength of associations or significance of remaining variables, so the full model is reported. We evaluated linearity in the GLM using residual plots based on standardized deviance residuals plotted against PHAC on the logit scale. We calculated variance inflation factors for each independent variable to ensure there is no collinearity problem among the common acuity measures.

We set significance a-priori at p<0.05, and present results as odds ratios (OR) with 95% confidence intervals (CI). Statistical analyses were performed by biostatisticians in R, version 3.2.3 (R Foundation for Statistical Computing, Vienna, Austria, 2015, https://www.R-project.org ).

From the rank-based analyses, we found notable associations with PHAC for the following 5 common measures: percentage of patients with ESI 1 or 2, CMI, academic status, annual ED volume, and inpatient admission rate. We did not find statistically significant associations with the percentage of Medicare patients or patients-seen-per-attending-per-hour ( Table 2 ).

Rank-Based Analyses: Strength of Association with the Proportion of High Acuity Charts in an Emergency Department 1 , 2

Scatterplots suggest the percentage of patients with ESI 1 or 2, CMI and the percentage of Medicare patients are linearly related with PHAC. Bell-shaped loess smooth curves from the scatterplots for annual ED volume, inpatient admission rates and patients-per-attending-hour suggest potential non-linear relationships with PHAC ( Figure 2a–f ).

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Scatterplots for the Associations between Common Acuity Measures (Continuous Variables) with the Proportion of High Acuity Charts

Results from univariate analyses using quasi-binomial GLM are consistent with findings from rank-based analyses. We found similar notable associations between the following 5 acuity measures and PHAC: percentage of patients with ESI 1 or 2, CMI, academic status, annual ED volume and inpatient admission rate ( Table 3 ). When all acuity measures are included in one model, only academic status demonstrated a statistically significant association with PHAC, and annual ED volume is borderline (p=0.052). The R 2 from this full model accounts for less than half of the PHAC variability. No systematic patterns against randomness around 0 were observed from residual plots of each acuity measure from the full model. Results using linear regression are similar to quasi-binomial GLM, but with lower R 2 for both univariate analyses and multiple linear regression, which indicates quasi-binomial GLM is a more appropriate modeling approach.

Regression Analyses: Relationship between Common Measures of ED 1 Patient Population Acuity and the Proportion of High Acuity Charts (PHAC) 2

Through univariate quasi-binomial GLM, we quantified the change in PHAC associated with a unit of change in each measure. Specifically, PHAC increases by 3% with a 1% increase of patients categorized as ESI 1 or 2, increases by 8% for each 0.1 unit increase in CMI, and increases by 9% for each 10,000 patient increase in annual ED volume. The ratio of AMC affiliated ED and primary AMC ED PHAC to non-academic EDs was 1.73 and 2.04 respectively.

We found the percentage of patients with ESI 1 or 2 had the strongest association with PHAC followed by CMI and annual ED volume. Academic status captures variability outside of that explained by ESI, CMI, annual ED volume, percentage Medicare patients, or patients-seen-per-attending-per-hour as evidenced by retaining its significant association in the multiple regression analysis. We found no significant relationships between PHAC and the percentage of Medicare patients, inpatient admission rate, or patients-seen-per-attending-per-hour.

Emergency Severity Index (ESI) Scoring

The percentage of patients with an ESI score of 1 or 2 had the strongest, albeit moderate, correlation with PHAC. These are patients anticipated to need immediate attention for a potentially life or limb threatening condition. ESI is a prospectively applied score that considers illness urgency and intensity of anticipated services. It is calculated for the majority of individual ED patients shortly after arrival and prospectively estimates acuity using vital sign instability, signs of distress, symptoms associated with urgent medical needs, and the clinical judgement of emergency medical service personnel and triage providers. The ESI’s inclusion of objective findings, clinical judgement, predetermined symptoms of concern, and the majority of ED patients likely impart a significant advantage over the other measures which primarily rely on retrospectively assessed administrative data. Given these characteristics, we anticipated a stronger association in our regression analysis, and a more positive slope in Figure 2f . We found a more moderate correlation than we anticipated. This may be due to limitations of the measure as it scores anticipated needs and does not account for the actual illness level determined or resources used during the ED visit.

Case Mix Index (CMI)

CMI also had a moderate correlation coefficient. It is a complex measure designed to capture the intensity of in-hospital care provided to admitted Medicare or Medicaid patients. The adjusted association, however, was not statistically significant. Our loess curves of the relationship with PHAC ( Figure 2a ) showed a slope of nearly 1, but it appears to be significantly influenced by two outliers. The linear model demonstrates a more positive slope that may plateau in higher CMI facilities, thus reducing the strength of the association overall. However, this is unclear given there are few EDs with CMI >2.3. CMI’s major limitation is it excludes the majority of patients, those who are discharged from the ED or admitted to observation. The ability of CMI to stratify acuity within the admitted patient subgroup likely accounts for its discrimination of PHAC across EDs.

Annual Emergency Department (ED) Patient Volume

Annual ED volume had a moderate correlation with PHAC. This may be because, although it accounts for the full ED patient spectrum, it provides no information on services or illness level for individual patients. Nonetheless, prior work has demonstrated an ED will function differently and require an increase in the intensity of resources to meet care demand with every 20,000 patient increase in annual ED volume, 2 – 4 This increase in acuity with rising volume is seen in our data ( Figure 2b ). The relationship demonstrates a sharp rise until EDs reach 60,000 patients per year, then the trend levels off. A more linear trend in the higher volume EDs may be difficult to detect in this study due to there being only 7 EDs with annual volume >100,000 visits. Greater representation of larger volume EDs may demonstrate a stronger association.

Academic Status

There was a clear distinction in acuity between the academically-connected EDs and non-academic community practice sites illustrated by the medians of the academic groups being not only higher than non-academic EDs, but also falling outside of the non-academic ED interquartile range. In Figure 3 , however, we did not observe a significant distinction in the distribution of acuity between primary academic medical center (AMC) EDs and academically-affiliated EDs. AMCs serve as teaching centers partly because they provide a mix of patient acuity adequate for trainee education. As a result, they tend to be urban, tertiary care referral centers, with high acuity patient populations. It is, however, possible that resident and attending physician documentation may comparatively increase the care captured in patient charts and augment the resultant APC coding. Academic-affiliated sites are typically the community practice experience locations for trainees, thus a step away from the tertiary care hub function of many primary academic centers. As a result, we anticipated a significant difference from primary AMC sites. It may be that academic-affiliated sites benefit from added resident staffing in a practice environment were attending physicians document for the majority of patients. This increased documentation may augment coding. This is in contrast to primary AMC EDs where attendings more typically review resident documentation for most patients and may be more engaged in bedside teaching for a larger proportion of trainees than charting.

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Histogram for the Association of Academic Status with the Proportion of High Acuity Charts

Inpatient Admission Rate

We found a moderate correlation coefficient and a no significant regression associations between inpatient admission rate and PHAC. It seems intuitive that a higher percentage of patients admitted under inpatient status would indicate a sicker patient population. Hospitals, however, have varied thresholds for admission and varied ED resources. In some cases, more intense ED care may obviate inpatient admission. This makes it difficult to compare one ED’s admission rate to another. In addition, this measure reveals little about the care provided during the ED stay, and does not represent the majority: those discharged or admitted to observation. The mean inpatient admission rate have been previously reported as 17.5%. 16 This is similar to the 18% observed in our study. The scatterplot demonstrates a sharp rise until inpatient admissions reach approximately 18–20% with an IQR of 14–24% ( Figure 2d ). We anticipated this variability, within the interval with the steepest slope, would reliably discriminate acuity across EDs, as is often assumed in practice. However, the moderate correlation observed suggests other factors may contribute to the admission decision. Some EDs may provide more extensive diagnostic testing or treatment permitting discharge that, if deferred, could qualify a patient for inpatient admission. (i.g., cardioversion for atrial fibrillation with a rapid ventricular response; 17 , 18 or young patients with suspected infection who present with hemodynamically unstable vital signs, improve with resuscitation, and are discharged with home care). This may be due to most EDs lying within the plateau area of the loess curve in the scatter plot ( Figure 2e ). Additionally, this metric is vulnerable to variable leveling as inpatient versus observation status across institutions. This may create artificial differences between similar patient populations. For example, a 2013 OIG report found significant variation across hospitals in the relative mix of long outpatient stays and short inpatient stays. 17 This may explain why the OR for inpatient admission rate were 1.0 in both our univariate and multivariate regression analyses.

Percentage of Medicare Patients

We found a weak association with PHAC and the percentage of Medicare patients. A larger percentage of ED Medicare beneficiaries would seem to introduce a larger patient cohort with higher risk for severe illness due to increased age, number of comorbidities, and frequency of healthcare utilization. This group, however, is generally a minority subset of the larger ED population and thus this measure does not account for the service or illness for the majority of patients. We observed a slight, but non-statistically significant, trend towards an increasing percentage of high acuity charts with an increasing Medicare population ( Figure 2c ). The lack of association in our correlation or regression analyses suggests any association with acuity is indirect.

Patients Seen Per Attending Hours Per Day

A high patient to attending physician ratio, measured as patients-per-attending-hour, is assumed to correlate with a lower acuity ED. The rationale is if one physician can see many patients, the intensity of care and level of illness of the broader patient population is likely low. We observed an initial rise in the association of patients-per-attending-hour, an inflection around 3 patients per hour, then a downturn ( Figure 2e ). The progression from 1–3 patients per hour may be reflective of higher acuity with ≥3 patients per hour is consistent with a low acuity environment. Nursing, resident, and physician extender staffing levels, in addition to facility design and other variables such as the use of scribes may impact the productivity of an attending physician. This efficiency effect is a difficult confounder to quantify. 20 Alternatively, physicians seeing ≥3 patients per hour may not have the time to provide the same attention to documentation details thus resulting in a lower billing acuity. This parabolic association, however, did not demonstrate significant influence in our study. Further investigation into the dynamics responsible for inflection at ~3 patients per hour warrants further investigation.

LIMITATIONS

There is no established reference standard for retrospectively measuring ED patient population acuity. As a result, we present our study as a thought provoking analysis exploring the validity of several traditional acuity measures for cross-facility comparisons. Participating EDs are members of a voluntary reporting organization motivated to share these metrics for the purpose of research. This likely introduces selection bias into the sample. To reduce this bias, the EDOSG strategically recruits EDs from all regions of the US with attention to the diversity of ED types (size, population served, urbanicity, and academic status) as is reflected in Table 1 . The study uses an administrative data set, however, the data were collected with the intent of informing this specific study. The sample size is small with 27 of the 54 EDs sending complete data. However, 88% of the data requested was received, and we applied multiple imputations to our Complete Outcome Cohort (54) to reduce the bias introduced by a small data set ( Figure 1 ).

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ED Inclusion/Exclusion Diagram

The objective of our modeling was to quantify each common acuity measure’s association with PHAC using this sample, rather than generating probabilities for unobserved EDs. As a result these findings should be considered suggestive given the limitations described above. Many multi-center studies of this type are limited to focal regions of the US or a particular type of ED. In addition, they often include academic centers with an interest and an incentive to perform research. This data set includes representation of the geographic and demographic diversity of EDs in the US including sites not typically involved in clinical research. There is less representation of the West and Midwest; however the proportional regional representation mirrors the population distribution of the US.

Our outcome variable is a percentage (or fraction) rather than a continuous variable, which involves loss of information on the acuity of individual patients within each ED. However, our primary objective was to capture the presence of a subset of truly acute patients within each ED. In addition, a fractional response outcome permits the use of a quasi-binomial linear model with a logit link allowing us to include variables into the analysis without major transformations that risk over-fitting the model to the idiosyncrasies of our sample. Despite our concerns over assuming linearity, our linear regression results mirrored that of the GLM. PHAC’s dependent on the translation of medical record data to acuity scoring for billing reimbursement may introduce information bias and selection bias. In a study examining the accuracy of coding-based billing compared to coding from direct observation, they found agreement amongst different coders in only 55% of patient visits. 21 Other studies have documented similar agreement level with the use of similar methods. 22 , 23 However, under and over estimating the intensity of services provided was equivalent suggesting that aggregate summary measures of patient visits over time may be valid. In addition, much of this prior research was done at a time when our current coding and reimbursement system was being introduced to medicine. Contemporary provider practices have likely adjusted. However, longitudinal research using billing data should account for this confounder. Transitioning electronic medical record systems has been known to impact the quality of documentation and the accuracy of billing. However, none of the EDs in this sample were involved in an EMR system change during the study period.

Our unit of analysis is the ED, and PHAC is an aggregated measure for individual EDs. As a result we have not weighted the PHAC for number of patients included at each hospital. This was handled in our analysis with the use of the logit link. The use of a fractional response outcome prevents one from using our model to estimate the acuity for an ED that was not included in our sample. Even if we had weighted our outcome variable, the low odds ratios obtained would not yield reliable estimates of PHAC. 20 This was a study performed on an available dataset, and the sample size did not permit traditional internal validation procedures. However, we boot strapped our confidence intervals to validate the associations of acuity. As a result of this discrepancy, our analysis should be repeated in a larger sample to assure external validity before widespread adoption of our results.

The percentage of ESI 1 or 2 patients had the strongest association with PHAC followed by CMI and annual ED volume. Academic status captures variability outside of that explained by ESI, CMI, annual ED volume, percentage Medicare patients or patients-seen-per-attending-per-hour. The relative strengths of association observed in our study suggest a hierarchy of quality as measure for ED acuity, but should be examined in a larger data sample. All measures combined only explained 42.6% of PHAC variation so the validity of their common use as proxies for ED acuity should be further investigated.

Acknowledgments

GRANTS: Dr. Yiadom is supported by the National Heart Lung and Blood Institute (NHLBI) award numbers 5K12HL109019 and 1K23HL133477, and the National Center for Advancing Translational Sciences/NIH UL1 TR000445. Funding from this grant supported her effort on this project, data collection, biostatistical analysis, and manuscript development. Dr. Storrow is supported by NHLBI 5K12HL109019, NHLBI RO1HL111033, National Center for Advancing Translational Sciences/NIH UL1 TR000445, and PCORI FC14-1409-21656. He has received grant support from Abbott Diagnostics and Roche Diagnostics. He is a consultant for Roche Diagnostics, Novartis Pharmaceuticals Corp, Alere Diagnostics, Trevena, Beckman Coulter, and Siemens. Dr. Barrett has received research support as site principal investigator from Janssen Pharmaceuticals, Raritan, NJ and Alere, San Diego, CA. He is a consultant for Red Bull GmbH, Fuschl am See, Salzburg and Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, Connecticut. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

CONFLICTS OF INTEREST Dr. Yiadom is the founding director of the ED Operations Study Group

AUTHOR CONTRIBUTIONS :

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Demystifying Level 4 Emergency Care: A Comprehensive Guide

  • bởi Thành Công
  • Tháng Chín 27, 2023

A Simplified Explanation Of Emergency Department E/M Coding

Level 4 Trauma Center: What Is This Emergency Care Designation?

Keywords searched by users: What is level 4 emergency care emergency room levels 1-5, level 4 er visit examples, ec level 4 meaning, level 4 er visit criteria, level 4 emergency room visit cost, what is level 5 emergency room visit, memorial hermann ec level 4, level 5 er visit criteria

What Does Level 4 Mean In Er?

In the emergency room (ER), patients are categorized into different priority levels to ensure that those in need receive timely care. These priority levels are determined by the triage registered nurse, who assesses both your medical history and current condition. The scale used for assigning priority levels consists of five levels in total. Here’s a breakdown:

  • Level 1: Resuscitation (Immediate life-saving intervention)
  • Level 2: Emergency
  • Level 3: Urgent
  • Level 4: Semi-urgent
  • Level 5: Non-urgent

Level 4, which is labeled as “Semi-urgent,” represents patients whose medical conditions are significant and require attention but are not immediately life-threatening. This prioritization system helps ensure that patients are seen in order of the severity of their medical needs, allowing for efficient and effective care delivery in the ER.

What Is Level 4 Triage?

Since the turn of the millennium, there has been a notable shift in the healthcare industry towards the establishment of standardized triage acuity scales. These scales are designed to categorize patients into different levels based on the urgency of their medical needs. One commonly adopted system consists of five distinct levels:

  • Resuscitation
  • Less Urgent

Level 4 triage, often referred to as “Less Urgent,” occupies a pivotal position within this framework. It identifies patients whose medical conditions, while not immediately life-threatening, still require prompt attention and care. This level helps healthcare professionals prioritize patients effectively, ensuring that resources are allocated appropriately based on the severity of their conditions. Consequently, understanding level 4 triage is essential for optimizing healthcare delivery and ensuring that patients receive the appropriate level of care.

What Is Level 5 In A Hospital?

In a hospital setting, patients are categorized into different levels of care based on the severity of their medical condition. These levels help healthcare professionals prioritize and allocate resources effectively.

Level 1 represents the most critical cases where there is an immediate threat to life, requiring immediate attention and intervention. Examples of Level 1 cases include severe trauma, cardiac arrest, or major bleeding.

Level 2, known as the Emergency level, includes patients who are in a serious condition that could become life-threatening if not promptly addressed. These cases require rapid evaluation and intervention, such as a severe asthma attack or a complicated fracture.

Level 3, termed Urgent, involves patients with medical issues that are serious but not immediately life-threatening. These individuals require medical attention relatively soon, but there is more time to assess and treat their conditions. An example might be a moderate respiratory infection or a minor bone fracture.

Level 4, which falls under Semi-urgent, encompasses cases that are not life-threatening but still require medical attention. These patients can generally wait longer for treatment without significant risk. Examples include minor burns or mild allergic reactions.

Finally, Level 5 is categorized as Non-urgent, indicating cases where treatment is needed, but the condition is not time-sensitive. Patients at this level can wait for care as time permits, as their conditions are not expected to worsen quickly. Examples include non-severe rashes or minor sprains.

By categorizing patients into these levels, healthcare providers can efficiently manage their resources and ensure that the most critical cases receive immediate attention while still addressing less severe conditions in a timely manner.

Top 35 What is level 4 emergency care

A Simplified Explanation Of Emergency Department E/M Coding

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Level 4 Trauma Center: What Is This Emergency Care Designation?

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level 4 er visit meaning

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COMMENTS

  1. Leveling of Emergency Room Services

    When a hospital, free-standing emergency center or physician bills a Level 4 (99284) or Level 5 (99285) emergency room service, with a diagnosis indicating a lower level of complexity or severity, the health plan will reimburse the provider at a Level 3 (99283) reimbursement rate. Critical Access Hospitals are exempt from this policy when they ...

  2. Why Did My Emergency Room Visit Cost So Much?

    ER level 1-2 visits are reserved for treatment of mild cases like bug bites and sunburns. The majority of ER visits fall between ER visit levels 3-5, with ER visit level 4 being the most common, Fries says. "Most emergency room claims will qualify as a 99284, because you only need something as simple as IV fluids to get you there," Fries says.

  3. Emergency Department Visits

    99283 (G0382) Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low medical-decision making. Any interventions from above, plus any below: Receipt if EMS/Ambulance patient. Heparin/saline lock. One Nebulizer treatment.

  4. What are the differences between emergency room levels?

    MDLIVE. Emergency Departments (ED's or ER's) are categorized into five levels of care. Level I is the highest level and must have immediately available surgical specialists and sub-specialists (surgeons, neurosurgeons, orthopedic surgeons, anesthesiologists, plastic surgeons) in order to handle the most severe and complicated injuries.

  5. A Quick-Reference Card for Identifying Level-4 Visits

    KEY POINTS: A few simple rules of thumb can help you remember when a code of 99214 might be indicated. The author uses his reference card as a reminder of what must be documented to support a ...

  6. Coding and Billing Guidelines for Emergency Department

    Coding & Billing Guidelines. Emergency Department (ED) Evaluation and Management (E/M) codes are typically reported per day and do not differentiate between new or established patients. There are 5 levels of emergency department services represented by CPT codes 99281 - 99285. The ED codes require the level of Medical Decision Making (MDM) to ...

  7. Coding Level 4 Office Visits Using the New E/M Guidelines

    The overall level of the visit is determined by the highest levels met in at least two of those three elements. That means that for an outpatient E/M office visit to be coded as a level 4 (for new ...

  8. What to expect in the emergency department

    Every patient who visits the emergency department (ED) will go through triage, which allows the ED team to establish the severity of that person's condition. Triage takes into account the patient's vital signs, as well as his or her complaint. Dr. Oyler says measuring the patient's vital signs is the most crucial component of triage ...

  9. Coding tips: Level 3 vs. 4 evaluation and management

    If the EHR gives credit for this information, physicians need to recognize that the E/M level may be inflated, and they should override the code manually, she says. CPT code Description 2018 national average Medicare Payment. 99203. Level 3 office visit. New patient. $109.80. 99204. Level 4 office visit. New patient. $167.40. 99213. Level 3 ...

  10. A Quick Guide To Identifying Level-4 Visits

    Understand and Recognize the Types of CPT Codes 2022. Coders to Know Where It's "AT" in Clean Chiropractic Claims. 99214. The total time needed for a level 4 visit with an established patient (CPT code 99214) is 30-39 minutes. The total time needed for a level 4 visit with a new patient (CPT 99204) is 45-59 minutes.

  11. Was that a level 4 E/M visit? Find the answer in just three ...

    The new rules should make it easier to avoid under-coding level 4 visits — a common and costly mistake. In fact, most level 4 visits can now be identified by asking just three questions: 1. Was ...

  12. A Simplified Explanation of Emergency Department E/M Coding

    There are only 3 components that determine the E/M level: 1. HISTORY. 2. PHYSICAL EXAM. 3. MEDICAL DECISION MAKING. As I go through this sample case I will demonstrate the minimum amount of documentation needed for the chart to be coded as a level 5 chart.

  13. 99284 Emergency Care

    Amount charged above is for the attending physician at the time of visit. You will get 4-5 separate bills for the emergency visit. In my case, went to ER for kidney stone, first time experiencing ER visit and what a sticker shock. 1 bill from the hospital, 1 bill for the attending doctor, 1 bill from radiology department.

  14. PDF Emergency Department Visit Leveling

    When a physician bills a Level 4 (99284) or Level 5 (99285) emergency room E/M service, with a diagnosis indicating a lower level of acuity, complexity, or severity, the service will automatically be reimbursed at the Level 3 (99283) reimbursement rate. The submitted procedure code will be changed to 99283 in the claims processing system and on ...

  15. What Is CPT Code 99284 & How To Know When To Use It

    CPT code 99284 is defined in the official CPT code book manual as being for "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components.". Component 1: Must include a detailed history. Component 2: Requires a detailed examination.

  16. Emergency Room

    Both Level 2 and Level 3 average prices for an ER visit rose about 6% per year over the past 3 years. Level 4 average price is $1,490. Top base price for a Level 5 visit was $2,097 per visit ($1,546 hospital, $551 doctor fee). Level 4 and Level 5 Emergency Department visits have risen about 5% per year, over the past 3 years in Vermont.

  17. A Revised Classification Algorithm for Assessing Emergency ...

    The New York University Emergency Department Algorithm (NYU-EDA) is widely used to classify emergency department (ED) visits. 1,2 This measurement tool's development occurred in the late 1990s ...

  18. A Step-by-Step Time-Saving Approach to Coding Office Visits

    Think time first. If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if it does not, go to ...

  19. Emergency Room Severity Levels

    Severity Level 5. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity.

  20. 2023 Emergency Department Evaluation and Management Guidelines

    The codes have not changed, but the code descriptors have been revised. In November 2019, CMS adopted the AMA's revisions to the Evaluation and Management (E/M) office visit CPT codes (99201-99215), code descriptors, and documentation standards. The revised CPT guidelines for office/outpatient E/M codes went into effect on January 1, 2021

  21. Measuring Emergency Department Acuity

    INTRODUCTION. Emergency department (ED) acuity may be defined as the general level of patient illness, urgency for clinical intervention, and the intensity of resource use within an ED's clinical care environment. In this context it is a characteristic encompassing the intensity of medical need and services delivered.

  22. Why visiting the ER costs so much money

    Paige Thoele was charged for a level 4 ER visit for treatment for a bladder infection "About 52 minutes from start to finish," she said. "The doctor saw me for about five minutes."

  23. Demystifying Level 4 Emergency Care: A Comprehensive Guide

    Keywords searched by users: What is level 4 emergency care emergency room levels 1-5, level 4 er visit examples, ec level 4 meaning, level 4 er visit criteria, level 4 emergency room visit cost, what is level 5 emergency room visit, memorial hermann ec level 4, level 5 er visit criteria

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