What is the difference? We'll tell you!
When looking for a job in the medical coding world, there is often some confusion between facility coding and professional coding. The main difference is that professional coding is mandated by CMS and facility coding is facility based. In this article, we are going to focus on the difference in the emergency room setting.
Professional E/M Coding
When coding professional evaluation and management (E/M) codes, CMS gives the option of choosing either 1995 guidelines or 1997 guidelines. The difference between the two is the physical exam documentation. Specialized providers prefer 1997 guidelines since their physical exams are more focused (i.e. podiatry, OB/GYN, etc.). Emergency room providers typically prefer 1995 guidelines as their physical exams are more generalized.
The professional E/M level is driven by the level of medical decision making (MDM). When determining the level of MDM, the coder takes into consideration:
- The number of possible diagnoses and/or the number of management options
- The amount and/or complexity of medical records and diagnostic tests
- The risk of significant complications and morbidity
After looking at the MDM and determining the level, the coder will count up the elements per the CMS guidelines. Each chart is broken down into sections (HPI, ROS, PFSH, and PE). Each section has a certain number of elements that needs to be documented. Even though the MDM drives the level, the number of elements has to be documented in order to assign that level. If the documentation is not there to support the level, then you have to down code to the level that the documentation does support.
Below is a graph with the number of elements required per CMS 1995 guidelines:
Facility E/M Coding
The facility E/M level is determined by the highest level of intervention that is provided to the patient during their ER stay. The interventions include, but are not limited to, diagnostic tests performed, medication administration, discharge instructions, etc.
CMS does not provide guidelines when it comes to determining the facility E/M level. Each facility can create their own E/M matrix.
To see an example of a facility E/M matrix, please click on the American College of Emergency physicians resource: https://www.acep.org/content.aspx?id=30428.
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