ED Coding and Reimbursement Alert

Fortunately, the 9 percent error rate in this category came down from last year’s total.

Emergency departments have a wide range of coding options, not only including the ED E/M codes, but also imaging studies, specimen collections, fracture care, and a host of other services. This could create confusion when selecting the right level of service, as evidenced by the $224 million in improper payments that CMS attributes to emergency department specialists.

The backstory: CMS issued its “2020 Medicare Fee-for-Service Supplemental Improper Payment Data” on December 21 as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the biggest errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found a 6.3 percent improper payment rate (8.1 percent for Part B) among claims submitted during the 12-month period from July 1, 2018 through June 30, 2019.

Emergency Visits Saw Higher Error Rate Last Year

On the list of services with the most Part B improper payments, CMS ranks emergency room visits high, logging a 9.1 percent error rate. This came down from last year, when ED specialists had an 11.7 percent error rate and logged over $290 million in improper payments.

The majority of the ED errors (50.5 percent) in the 2020 report were due to incorrect coding, while another 33.9 percent occurred because of insufficient documentation.

The insufficient documentation statistic may be particularly concerning to EDs, since that error rate was just 13.2 percent last year. The 20.7 percentage point increase may mean that emergency departments aren’t documenting as thoroughly as they used to be, which is potentially due to the complexity of hospital-wide EHR systems that simply are not easily adaptable to the challenging environment of the ED.

Based on the national error rate, the CMS statistics indicate that the ED visit error rate is nearly three percentage points higher than the overall Part B error rate of 6.3 percent.

Avoid These Common Errors

Although you may be focusing on the millions of dollars in errors recorded for ED practices, keep in mind that not all of them were due to overcoding. Many of the errors involved undercoding and underpayments, which meant that these doctors actually deserved more money than they collected. Of course, these types of problems are still considered errors and qualify as “incorrect coding,” so it would be best to put checks and balances in place to prevent these issues going forward.

The stats: According to the report, 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components …) alone had a 5.9 percent underpayment rate, which led to $7.3 million in underpayments.

On the flip side, some $8 billion in Part B payments were incorrectly paid due to upcoding errors, $99 million of which involved ED visits. For instance, 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components …) logged a 7.9 percent overpayment rate.

Incorrect coding: When it came to incorrect coding errors, emergency department visits ranked high on the total list of services with these issues. When listed among all service types, ED visit codes 99285 ranked eighth for most improper payments due to incorrect coding, at $106 million. It was topped by established patient office visits, initial hospital visits, subsequent hospital visits, new patient office visits, critical care, hospice, and nursing home care.

Are You Upcoding ED Visits?

With $99 million in ED visits being upcoded, you may be wondering if your practice makes up part of that number. As you review your coding practices, keep in mind that medical necessity should drive every code choice, says Tisha Gutierrez, CMC, CBMCS, CEMC, CGCS, coding manager with RevMD. “Documentation of the key elements and the medical necessity of the service being provided are crucial,” she notes.

Remember that ED visits currently require you to meet all three E/M criteria to select a particular code level. This is different than subsequent hospital care E/M codes 99231-99233 (which only require two of the three), and coders who use both code sets may tend to forget that all three requirements are necessary in the ED setting.

One area where coders can fall short is in the history of present illness (HPI). Because many issues seen in the ED are emergent, collecting information about HPI can  sometimes be forgotten, but it’s essential to keep a strong focus on this area. A brief HPI consists of one to three elements, whereas extended HPI requires four-plus elements.

The ED physician must perform an extended HPI to satisfy the requirements for a detailed or comprehensive history — meaning that extended HPI is a requirement for both 99284 and 99285. Extended HPI does not guarantee a 99284 or 99285, but it does make reporting them possible. The physician still has to satisfy the other elements of the service before choosing these high-level codes.

Checklist: For coding purposes, HPI is an ordered description of the patient’s current complaint, from the first sign/symptom to the ED encounter. When counting elements, you may encounter these examples in the physician’s documentation:

• What is the physical location of the problem on or in the body? (location)
• How is the symptom further described related to the type of pain (such as crampy or sharp)? (quality)
• How intense is the problem or related pain? (severity)
• How long has the patient had the problem? (duration)
• Is the problem better or worse at any time of the day? (timing)
• How did the injury occur? (context)
• What can the patient do to alleviate or aggravate the pain? (modifying factors)
• What other symptoms and signs does the patient have in relation to the chief complaint? (associated signs and symptoms)

Example: Notes indicate a patient reports to the ED complaining of left-sided sore throat (location) and wheezing (associated signs and symptoms) for the past two days (duration). He rates his pain as moderate (severity). Patient reports that the wheezing is worse at night (timing).

This is an extended HPI, as the physician documented five elements in the notes.