Health Information Management

You can have differing payer requirements for revenue codes

APCs Insider, October 17, 2008

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Assume that a managed care organization wants a hospital to bill all non emergency ED claims using revenue code 451 (EMTALA emergency medical screening services; charges for emergency treatment to... persons who require immediate unscheduled medical or surgical care). The hospital refuses because 451 is a screening code. Is the managed care organization correct to ask the facility to bill a lesser code than the medical record supports? Is this a compliance problem for the hospital?

Not exactly: it is not unusual for various payers to instruct providers to apply the standard codes differently, based upon their individual billing guidelines. Don’t assume that one size fits all. If you configure your billing systems for one payer, it is unlikely that any other payer with different guidelines will pay you. However, most systems can accommodate payer-specific billing rules.

Reporting revenue codes 450 and 451 in accordance with the instructions from this managed care organization (for their claims only), with adequate documentation, is not a compliance, billing, or coding problem.

(This tip was adapted from Briefings on APCs. To view the entire article, click here.)

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