ACEP ED Facility Coding Guidelines: Complete Introduction for Emergency Department Billing

 In the busy environment of an Emergency Department (ED), accurate coding is essential for both compliance and fair reimbursement. While ED physician coding captures the medical decision-making of providers, facility coding measures the resources and services the hospital uses—such as nursing care, supplies, and monitoring equipment.

To bring clarity and consistency to this process, the American College of Emergency Physicians (ACEP) created the ACEP ED Facility Coding Guidelines. These guidelines help hospitals determine the correct ED facility level (1–5) for billing, based on the intensity of facility resources used during a patient visit.

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What Are the ACEP ED Facility Coding Guidelines?

The ACEP ED Facility Coding Guidelines are a structured framework that hospitals can adopt or adapt to their own operations. The goal is to:

• Create clear, auditable, and consistent facility coding standards.

• Align with CMS Outpatient Prospective Payment System (OPPS) principles.

• Prevent upcoding or undercoding by linking levels to actual interventions.

• Provide a nationally recognized reference model for hospitals and coders.

These guidelines are especially important because CMS does not provide national ED facility coding rules, leaving hospitals responsible for developing their own compliant methods.

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How ACEP Facility Coding Works

The ACEP ED facility coding model organizes coding into three columns:

1. Facility Codes & APC Levels – Each ED visit is assigned a level (1–5) linked to an Ambulatory Payment Classification (APC).

2. Possible Interventions – Actions by nursing or ancillary staff (e.g., complex wound care, multiple IV medications).

3. Potential Symptoms/Examples – Situations where such interventions may occur (for reference only).

Key rule: The facility level is determined by the interventions, not the presenting symptoms.

Example:

• Low complexity: Vitals, single oral medication → Level 1 or 2.

• High complexity: Cardiac monitoring, multiple IV meds, complex procedures → Level 4 or 5.

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ACEP Guidelines and CMS Principles

The ACEP ED Facility Guidelines follow CMS’s 11 OPPS guiding principles, including:

• Relating resource intensity to the level of service.

• Basing levels on facility, not physician, resources.

• Ensuring clarity for coders and auditors.

• Avoiding excessive documentation requirements.

• Being verifiable during audits.

These principles help hospitals avoid compliance risks and maintain consistency in coding practices.

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Why ACEP Facility Coding Matters for Hospitals

Following the ACEP ED facility coding guidelines offers key benefits:

• Accurate reimbursement for hospital resources.

• Reduced audit risk by following a recognized model.

• Better workflow consistency among coding staff.

• Support for payer requirements, as some insurers use ACEP’s model for claim reviews.

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ACEP Facility Coding Series

This article is part of our ACEP ED Facility Coding Series. In upcoming posts, we’ll cover each facility level in detail:

1. ACEP ED Facility Level 1 – Minimal Resource Use

2. ACEP ED Facility Level 2 – Low Resource Use

3. ACEP ED Facility Level 3 – Moderate Resource Use

4. ACEP ED Facility Level 4 – High Resource Use

5. ACEP ED Facility Level 5 – Very High Resource Use

6. Critical Care – Highest Resource Use with CPT 99291/99292

Each post will include:

• Definition of the level.

• Common interventions.

• Example patient scenarios.

• Documentation tips.

• Common coding mistakes to avoid.

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Final tip: Hospitals should customize ACEP’s guidelines to their specific workflows while staying true to CMS principles. Training coding staff and auditing regularly ensures ongoing compliance and accuracy.