ED Coding and Reimbursement Alert

From missing documentation to collecting patient balances, bring in more cash with these tips.

Although the emergency department is often the first place patients go when they suspect they have COVID-19, the pandemic has also caused some people to stop visiting EDs for other emergent reasons due to fear of exposure to the virus. This reduction in volume has caused many emergency departments to see income fall, with some struggling quite a bit financially due to the pandemic.

To ensure that your ED isn’t overlooking any hidden sources of cash, we sat down with the staff of 360 Medical Billing Solutions, an outsourced billing firm based in Oklahoma City, Oklahoma, that works specifically with emergency department groups and urgent care offices.

Check out the team’s top 10 tips for bringing in money that some EDs may be overlooking.

1. Check Diagnosis Sequencing

In some cases, ED providers may forget to document all applicable diagnosis codes from the patient encounter, says Michelle Cook, RCM director. In other cases, the diagnosis codes are all in the documentation, but are sequenced incorrectly on the claims, she says.

“You should always report the most emergent condition as the first-listed diagnosis code,” Cook says. “If physicians fail to document this condition in the charts, that could have multiple repercussions. For instance, it could impact how you calculate your medical decision making, and it will definitely affect whether the insurer considers the patient’s situation to be truly emergent.”

2. Avoid Unspecified Diagnoses

You should also try to avoid unspecified diagnosis codes if possible, says David Windham, vice president and co-founder. “Unspecified chest pain is the type of diagnosis that could lead to denials — you should instead report the final, definitive diagnosis if you have one.”

For instance, if the physician reports a fracture, the documentation is likely to include the location and laterality, when applicable. Therefore, you shouldn’t have to resort to unspecified diagnosis codes for a condition like that, adds Christy Ragsdale, quality assurance director.

3. Confirm That All E/M Elements Are Present

Missing documentation can go beyond diagnosis coding, Ragsdale says. “Poor documentation is why EDs get so many downcoded claims,” she says. “Insurers review the records and see that there’s not enough documentation, so they change a level five E/M code to a level three,” she notes.

Considering that there’s a $110 difference in average reimbursement between ED codes 99283 and 99285, missing documentation is an expensive mistake to make. Therefore, Ragsdale says, it’s more important than ever for ED providers to document as thoroughly as possible.

“Insurers will often downcode without even reviewing records,” Ragsdale adds. “They do it based on the diagnosis code and then the team will submit records and the insurer will stand by their decision.”

4. Stay on Top of Shifting Insurer Regulations

“Insurance companies are always changing their policies,” Windham said. “Since 1990, we’ve seen HMOs, Medicaid providers, and private insurers run claims through an algorithm and auto-deny them based on things like diagnosis coding, but the issue subsided for a while and now it’s popping up again.” Therefore, you should stay on top of each payer’s changing requirements so you’re prepared for any shifts.

5. Verify Patient Coverage

As many EDs are aware, benefit plans have changed dramatically over the past few years, with patients facing higher deductible and coinsurance amounts and insurers paying a lower percentage of the ED costs. “It’s always a challenge for EDs to collect at the time of service,” says Rob Ross, vice president and co-founder. “But any efforts the ED can use to collect at the time of service will help their bottom line.”

Most ED practices are at the mercy of the hospital staff, which typically collects the patient’s information during registration, Ross says. But if possible, you should verify that the patient has active, verified coverage after the patient is stable and before they check out following their visit, he adds.

6. Scrub Your Claims

If you’re taking the provider’s claims and simply sending them to the insurer without scrubbing them first, you could face a high percentage of denials. “Claim scrubbing allows you to check for any possible data entry errors that could cause rejections at the payer level,” Ragsdale said. “The claim scrubbers will catch things like a missing fifth digit on a diagnosis code, a missing date of birth, and diagnosis codes that are no longer active.”

After 360 Medical Billing runs claims through a scrubber, the claims then go to a clearinghouse, where an additional scrubber analyzes the claims as well, Cook says. “Suppose we have Blue Cross Blue Shield listed as the payer, and we’ve only listed an eight-digit ID number. The clearinghouse’s scrubber would kick that claim out and tell us that Blue Cross requires a three-letter prefix followed by a nine-digit ID number, and would prompt us to fix it before we submit to the payer.”

By having every claim scrutinized up front, you’ll save yourself from denials later, Windham says. “It’s absolutely vital to do the scrubbing process. Otherwise you’re just kicking the claim further down the road to get it processed. It’s vital you have a team of employees who monitor that on a daily basis and check any errors you may have.”

7. Work Your Appeals

When Cook sees denials, she’ll go through the records and determine whether the documentation supports the codes billed. If so, she will immediately send an appeal letter along with supporting documentation.

“A really good source of additional money for ED physician groups would be making sure that the providers are on top of appeals and appealing downcodes with a well-written appeal letter and the documentation,” she says.

8. Run Aging Reports Frequently

After you submit a claim, your job isn’t done, Cook says. Instead, you should follow up on claims and ensure that the insurers pay you. “We run aging reports at 60 days because some payers do take a little longer to receive the claim, process it, and then send the explanation of benefits,” she says. “We have employees who work on claim follow-ups all day every day because it’s very expensive to just wait on insurers to pay. You have to always be watching the claim progress.”

9. Check Self-Pay Patients for Medicaid Eligibility

Not every patient who self-identifies as self-pay must be billed that way. In fact, some patients may qualify for Medicaid

and not realize it. “One very beneficial way EDs can bring in more money is to determine whether patients might qualify for Medicaid,” Cook says. “We have a system that we run all of our self pays through to check for Medicaid eligibility, and I feel like we get a lot of extra income off that. Billing uninsured patients with a statement and trying to collect that way produces almost no income, so it’s worth the extra time to evaluate Medicaid eligibility.”

You can help guide a patient to apply for Medicaid even if the ED visit has already taken place, Cook says. “Many states allow retroactive Medicaid billing going back for up to six months from when the patient applied for Medicaid,” she notes.

10. Offer Additional Payment Options

Because patients are often responsible for a large portion of their ED bills, you should provide them with a multitude of ways to pay, Windham said. “For instance, there’s an app that allows patients to take a picture of the statement with their phone and then submit a payment via mobile so they don’t have to write a check or call in to make the payment,” he says. There’s also a software program that allows you to email or text a patient and they can accept that and make payment via text and email, he notes. Just make sure it’s done compliantly. “The more ways you can provide patients to pay, the better the chances you will have of collecting from patients.”