Health Information Management

Q&A: Instructions for use of revenue codes 450 and 451 differ by payer

APCs Insider, July 11, 2008

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QUESTION: One of the managed care organizations in our state (who administers one of our Tenncare programs which is a Medicaid substitute) has asked us to change some emergency department (ED) codes and our billing department refuses to do so. Here are the details:
Our hospital ED has not implemented a screen and refer out program. All of our patients are triaged, prioritized, and receive services in the ED even if the services are non-emergent.   We bill these services using revenue code 450.  The managed care organization (because of an operational issue with the way they process claims) has requested that we re-bill all of the non-emergent claims using revenue code 451 (EMTALA emergency medical screening services; Charges for emergency treatment to those ill and injured persons who require immediate unscheduled medical or surgical care) which is a screening code. 
My question is whether it is appropriate from a compliance perspective to bill a lesser code that is supported by the medical record? 
ANSWER: Most state Medicaid programs have instructions for the use of revenue codes 45x which differ from Medicare?s requirements for use of these codes. In fact, it is not unusual for various payers to instruct providers to apply the standard codes differently based upon their individual billing guidelines. Your question concerning the 45x revenue codes  raises a very good question for all billing scenarios..
CMS issues national instructions and guidelines for the application of various codes. In many instances these codes are controlled or managed by another organization. The fiscal intermediaries (FIs) and Medicare Administrative Contractors (MACs) who are tasked with adjudicating Medicare claims also issue various instructions and guidelines which may or may not agree with the instructions from other FIs/MACs. Commercial payors, Medicaid programs, and managed care programs also have their own billing instructions and guidelines which may or may not agree with those issued by CMS or another payer. So how should a provider bill compliant claims?
Let?s begin by accepting that one size does not fit all. If you configure your billing systems based upon one payer, then it is likely you will never be paid by other payers that have different guidelines.  Thankfully, most systems can accommodate payer-specific billing rules using bridge or cross-over logic. Most providers face the biggest risk when they make changes to claims with little or no supporting documentation from the payer. Sometimes, providers make changes in response to a call regarding a single claim. The key to compliance is to get your payer?s guidelines and writing and require your compliance and legal departments to review them. Once they review the documentation, you should build routines and modify the claims to fit the payers? guidelines. You should build your systems using CMS/FI/MAC guidelines as the base, and change them for individual payers as needed. Review these changes annually for compliance with the payers? billing guidelines.
In summary, reporting revenue codes 450 and 451 in accordance with the instructions from the managed care organization (for their claims only), with adequate documentation, is not a compliance, billing, or coding problem.

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