One in eight visits to the emergency department is related to a mental health or substance abuse issue. That number has grown each year over the past decade.1 An informal poll of ACEP members showed that 100 percent of those asked had at least one behavioral health patient remaining in their emergency department for a multiple day stay in the past week.
Appropriate treatment for this vulnerable population is a high priority. An often loud and hectic ED setting is arguably one of the worst environments for a patient under mental stress. ACEP has long advocated for better access to facilities designed to care for behavioral health patients. The Improving Mental Health Access from the Emergency Department Act (H.R. 2519) was pushed forward by ACEP earlier this summer. This ACEP-drafted legislation would provide additional resources for patients with acute mental health needs who seek care in the ED due to a critical shortage of inpatient and outpatient resources. Working in parallel, the ACEP Coding and Reimbursement teams have been hard at work fighting for funds to care for these patients during their prolonged ED stays.
We all know that resources follow revenue. Historically, there was no approved way to capture the subsequent days of care provided after the initial ED visit, which was typically reported using the appropriate ED evaluation and management (E/M) code (99281–99285). As a result, long, multi-day mental health stays created both uncompensated care issues and further strained the safety net provided by our nation’s emergency departments.
Emergency providers faithfully support the safety net for our most vulnerable patients. We now have a mechanism and clear guidance to bill for multiday mental health stays.—Michael Granovsky, MD, FACEP
Due to the escalating mental health crisis, ACEP’s current procedural terminology (CPT) team has worked through the American Medical Association (AMA) CPT Editorial Panel and CPT Assistant, the monthly AMA publication that offers guidance related to correct use of the CPT code set, to seek a solution for this problem.
ACEP submitted a typical behavioral health vignette to CPT staff illustrating a patient who had presented with a behavioral health crisis who also required medical care while waiting to find an available inpatient psychiatric bed. The patient described presents with agitation, is severely decompensated, and has auditory hallucinations. The documented medical history reveals he has been off his medication for two weeks and has a prior suicide attempt. He has a history of diabetes and his glucose level is elevated. The plan is for a psychiatric admission, but no psychiatric beds are available at this hospital, and the patient remains in the emergency department for three days until he can be transferred. The patient remains under the care of the ED group for daily rounds, medication adjustments, and the management of any threats to the patient or hospital staff. On the third day, available space is found, and the patient is transferred to the psychiatric facility. Traditionally, coding guidance had been that “psych holding patients” did not meet the requirements to report observation services.
We asked CPT for direction on how to report days two and three of that stay. As published in the July 2019 issue of CPT Assistant, the AMA instructs physicians to report the appropriate ED E/M code, initial observation code (99218–99220) or critical care code, depending on the chart documentation, for the first day in the emergency department. For day two, CPT instructs us to use a subsequent observation day code (99224–99226) to capture the middle day (or multiple days) of a prolonged behavioral health stay in the ED setting. On the day of discharge from the ED setting, the discharging physician should report the appropriate subsequent observation day or the discharge from observation code (99217) based on the level of service documented.
Of note: Third party payment policies and unique contractual language may differ from CPT coding direction.
These new directions from CPT are helpful, as previously there was no way to report the extra days of care for the patients described here.
Table 1: Relative Value Units (RVUs) and Payments for Additional Mental Health Bed Hold Daily ED Services
|CPT Code||2019 Facility Total RVU||2019 Medicare Payment|
This represents an important win in our shared battle to improve support and funding for mental health care.
Previously: 99285 on day one and no charges for days two through five.
Total five day stay: 4.89 RVUs
Updated: 99220 day one (5.23 RVUs), 99225 days two through 4 (3 X 2.06 RVUs), day five 99217 (2.06 RVUs)
Total five day stay: 13.47 RVUs
Resources for these and other topics can be found on the reimbursement section of the ACEP website. ACEP Director of Reimbursement David McKenzie, CAE, is also available to field your questions at 800-798-1822, ext. 3233 or firstname.lastname@example.org. ACEP offers well-attended and highly recommended coding and reimbursement educational conferences annually, with an offering in January 2020 in Austin, Texas.
- Laderman M, Dasgupta A, Henderson R, Waghray A. Tackling the mental health crisis in emergency departments: look upstream for solutions. Health Affairs website. Published Jan. 26, 2018. Available at https://www.healthaffairs.org/do/10.1377/hblog20180123.22248/full/. Accessed Sept. 10, 2019.
Dr. Granovsky is President of LogixHealth, an ED coding and billing company, and currently serves as the course director of ACEP’s Coding and Reimbursement courses. He can be reached at email@example.com.
Mr. McKenzie is ACEP director of reimbursement. He may be reached at firstname.lastname@example.org.
Mental Health Visits Increasing in American Emergency Departments
By James J. Augustine, MD, FACEP
There has been a rapid rise in ED visits related to mental health issues. The latest data on this topic comes from the Centers for Disease Control and Prevention (CDC) and is current through 2016. From the 2016 National Hospital Ambulatory Medical Care Survey report on ED visits from the CDC:
- There were an estimated 145.6 million ED visits in 2016.
- There were 5.5 million visits with a primary diagnosis of mental disorder noted in the emergency department.
- At about 2.4 million visits, a mental health provider saw the patient in the emergency department.
- About 535,000 visits resulted in hospital admission to the mental health or detoxification unit of their hospital.
- About 1,130,000 patient visits resulted in transfer to a different hospital with psychiatric capability. Patient visits resulting in admission to some hospital for mental health issues totaled 2,164,000 ED visits, which is about 5,930 patient visits a day.
ED visits; visits by the homeless; visits where a mental health provider saw the patient in the emergency department; and visits where mental health patients were admitted all increased sharply from 2010 to 2016. It seems likely that similar increases continued to occur from 2016 to 2019.
The CDC underestimates the total ED visits in the country. A more comprehensive estimation comes from the National Emergency Department Inventory (NEDI)-USA database, which is maintained by the Emergency Medicine Network at Massachusetts General Hospital in Boston. NEDI-USA contains data on all U.S. EDs open since 2001. According to NEDI-USA, there were 5,381 U.S. EDs and 155,946,509 total U.S. ED visits during the year 2016. All state-specific and national summary NEDI-USA data for the year 2016 can be found here.
Dr. Augustine is director of clinical operations at EMP in Canton, Ohio; clinical associate professor of Emergency Medicine at Wright State University in Dayton, Ohio; vice president of the Emergency Department Benchmarking Alliance; and on the ACEP Board of Directors.