Difference Between ER Professional VS. ER Facility E/M Medical Coding

By  //  July 10, 2023

Due to the workflow involved, emergency treatment relies more heavily than many other specialties on skilled coders. In most ED settings, the emergency physician attends to the patient while recording the encounter.

In contrast to private practices, where physicians typically choose their codes, which may then be reviewed and verified by the in-house coder (but physicians make the majority of the coding decisions), it is then the responsibility of the professional coder to assign the appropriate codes according to the coding chart.

Most other medical specializations tend to receive less continuous and specialized training than ED coders. One explanation is the enormous range of medical illnesses that emergency physicians must manage daily and the variety of therapies they may administer.

The emergency physician and the emergency coder must handle every situation with precision and skill that allows little room for error, whether it be a heart attack or a car accident, fracture treatment or a fever, eye injuries, or giving birth. Internal and external audits of ED professional coders are demanding and common. To meet the increased level, any coder with less than 100% compliance must complete additional training.

What are the terms “ER Professional Medical Coding and ER Facility E/M Medical Coding?

A patient’s evaluation and management services supplied by a licensed provider are coded under “ER Professional Coding.” Each provider and the service they give will have their unique code. The term “ER Facility Coding” describes how the facility codes its services, including diagnostic tests, supplies, prescriptions, and other services.

These codes are typically based on the American Medical Association’s (AMA) Current Procedural Coding System (CPT). ER Facility Coding is used to document the cost of the service and is reported on the facility’s billing statement or permission form. ER Professional Coding is used to enter the amount of medical treatment provided to the patient and is written on the service provider’s remittance advice.

Professional E/M Coding

According to CMS, professional evaluation and management (E/M) codes can be coded using either the 1995 or the 1997 criteria. The documentation of the physical test distinguishes the two. Specialized clinicians (such as podiatrists, OB/GYN, etc.) prefer the 1997 recommendations because their physical exams are more concentrated. Since their physical examinations are more generalized, emergency room providers often prefer the 1995 recommendations.

The level of medical decision-making (MDM) determines the professional E/M level. The coder considers the following factors while calculating the level of MDM:

  • The variety of potential diagnoses and treatment options
  • The quantity and complexity of diagnostic tests and medical records
  • The possibility of significant complications and mortality 

Why do hospitals employ ER Professional E/M Medical coding?

Because it guarantees precision and consistency when establishing billing records and claims linked to patient visits, ER Professional E/M medical coding services are employed in the healthcare industry. It allows coders to precisely record details about a patient’s condition, the service they received, and the time a practitioner spent with them.

For medical practitioners to submit their claims for payment promptly and efficiently, it also facilitates electronic billing systems. Using a coding system reduces the likelihood of coding errors, guards against under and overbilling, and shields patients and providers from risky financial situations. Additionally, it facilitates the collection of better data to track patient outcomes over time, enhancing patient care.

Facility E/M Coding

The patient’s most significant level of intervention during their ER stay is used to calculate the facility’s E/M level. The interventions could involve performing diagnostic tests, giving medications, giving discharge instructions, etc.

The facility E/M level cannot be determined using the CMS’s criteria. Every facility is allowed to design its own E/M matrix.

Why do healthcare professionals use Facility E/M Coding?

Specialty-specific medical providers and Healthcare Administrative Partners such as Dental Billing Company, Services uses facility E/M coding to maximize compensation for services rendered and guarantee correct patient visit documentation. Additionally, they use it to record and collect payments from inpatient and outpatient facilities for services connected to patient diagnosis, treatment, and evaluation.

The amount of time, technical services, medical judgments, and other resources used to treat the patient are all factors considered by facility E/M coding, as well as the type of facility the patient visit occurred in (hospital or outpatient). With the help of this system, healthcare professionals may more precisely record their services, ensuring they are paid fairly for the time and effort they invest in caring for patients.

Furthermore, Facility E/M Coding helps medical offices, and professionals manage their budgeting process more effectively, enabling them to better plan for staffing and resources. Additionally, this coding system helps guarantee adherence to coding and billing regulations, streamlines the coding and billing procedure, and offers the facility an accurate audit trail.

ER Professional and ER Facility E/M Medical Coding: Significant Differences

One of the most significant distinctions between ER Facility E/M and ER Professionals is the reimbursement guidelines applied to the coding. While ER Facility E/M is the suggested coding set for more extensive ER facilities that incorporate a triage and treatment process, ER Professional is advised for individual doctors who stabilize and treat patients in the ER. Each organization should carefully assess its unique reimbursement requirements because the laws and regulations of the two code sets differ significantly.

Level of Documentation: For billing and payment, several documentation groups are needed for ER Professional and ER Facility E/M medical coding. The patient’s primary complaint, past medical history, treatment choices, and services rendered must all be documented for ER Professional coding. 

A face-to-face interaction with the patient, a review of the systems, a review of prior medical history, a study of family history, and the ability to diagnose and treat illnesses are all required for ER facility E/M medical coding, on the other hand. Doctors should be conversant with documentation requirements to code appropriately for ER services.