This article was originally published on June 23, 2022 and has been updated in October 2023.

Blue & Co. has performed many Emergency Department Leveling Reviews for hospitals. The two most utilized leveling criteria are “points-based” or “intervention-based.” In either case, each hospital must determine which facility resources (or attributes) to include within its criteria, and how these resources crosswalk into ED visit levels (99281-99285). This can create significant reimbursement differences between similar hospitals.

We also find that hospitals miscode Emergency Department (ED) visit levels due to a variety of issues. Commonly, we find documentation insufficiencies, inconsistent flow of clinical documentation through the electronic health record (EHR), and/or other undiscovered charge capture opportunities.

Many facilities are not aware of how their operations and internal criteria impact revenue capture for ED visit levels. In addition, many are unaware of how their ED visit “bell curve” compares to peer hospitals, and other benchmarking statistics (e.g., Program for Evaluating Payment Patterns Electronic Report; PEPPER).

Current Emergency Department Leveling Regulations

Since implementation of the Medicare Outpatient Prospective Payment System (OPPS), CMS has required hospitals to report facility Emergency Department (ED) visits using CPT codes 99281-99285. In the absence of national guidance, hospitals are expected to develop their own internal ED leveling criteria based upon the intensity of hospital resources (not physician work). In addition, the leveling criteria should follow the 11 principles published within the 2008 OPPS Final Rule.

How Blue Can Assist Your Organization?

Blue & Co. can assist your hospital with a free preliminary analysis comparing your facility ED visit levels with state and national percentile rankings. Our analysis will also determine your ED bell curve ranking amongst peer hospitals. This analysis may discover potential opportunities for cash flow and compliance improvement.

Should your facility have potential opportunities, we can help with a root cause analysis and implementation assistance customized to your facility.

Emergency Department Leveling Case Study

Blue & Co.’s Revenue Cycle team put together a case study looking at a two hospital system and the results the system had after Blue helped implement Emergency Department leveling criteria. To read through the case study, fill out the form below.

Contact Us

To learn more about how Blue & Co. can help identify what opportunities may exist within your organization or to learn more about Emergency Department Leveling Reviews please reach out to your local Blue & Co. Advisor or a member of our revenue cycle team listed below.

Heather Reagan, CPC, CCS-P, CPMA
Revenue Cycle Manager
317.275.7420