ED Coding and Reimbursement Alert

Incorrect coding was the biggest culprit among ED providers’ claims.

Emergency medicine providers not only perform E/M services every day, but they also read imaging studies, perform procedures, and review lab reports — among many other responsibilities. This range of services can lead to a wide swath of coding rules to understand, which could create confusion when selecting the most accurate code. Perhaps this explains the $190 million in improper payments that CMS attributes to emergency department specialists.

Background: CMS published its “2021 Medicare Fee-for-Service Supplemental Improper Payment Data” on December 7, 2021, 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 (8.5 percent for Part B) among claims submitted during the 12-month period from July 1, 2019 through June 30, 2020.

Emergency medicine providers logged an 8.7 percent improper payment rate — higher than the overall average, but lower than the 9.1 percent error rate that ED specialists experienced last year. Although 2021 was certainly a year that presented new challenges, from seeing more patients via telehealth to understanding new codes, billers and coders are still expected to code and bill their ED specialists’ services properly.

Incorrect Coding Among Biggest Issues for ED Specialists

When it came to the reasons behind ED specialists’ improper payments, incorrect coding was the biggest culprit, representing 62 percent of the errors. Close behind was insufficient documentation at 20.3 percent.

When it comes to incorrect coding, reviewers note this type of error when you report the wrong code for a service, either via upcoding, downcoding, or miscoding.

For example: A provider reports 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity…) for a visit with a patient. The documentation demonstrates that the ED physician performed a problem-focused history, an expanded problem-focused exam, and medical decision making (MDM) of moderate complexity. Although the documentation supports the required physical and MDM levels for 99283, the history only justifies reporting 99281. Therefore, the visit is downcoded to the level-one ED code.

Remembering that the physician’s documentation is key to supporting every code level. When it comes to errors classified as having insufficient documentation, that doesn’t necessarily mean your ED practice has lost or truncated its existing documentation — instead, it often means that the provider didn’t document enough in the first place to justify the services you billed.

Example: The physician’s documentation for an E/M service states, “Patient presented to the ED evaluate stomach pain.” The record lacks a date of service, an explanation of any exam performed or history of present illness, and may also be missing many other details. Therefore, the reviewer marks this claim as non-payable since it is lacking even the most basic information that would allow it to qualify for an E/M code (99281-99285).

In addition, documentation might be lacking for procedures as well as for E/M codes. For instance, some physicians tend to only indicate what they find that is abnormal when completing documentation, says Barbara J. Cobuzzi, MBA, CPC, COC,

CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey. “So, instead of indicating all of the anatomical areas viewed when performing a diagnostic endoscopy, the physician might only list the problem areas. But auditors expect to see documentation of all areas viewed and confirmation that the full anatomy was examined. As such, make sure that the full anatomy that an endoscopy reviews is addressed in the documentation, listing both normal findings and abnormal findings.”

Check Which E/M Codes Featured the Most Errors

CMS breaks down which codes had the most incorrect coding errors among all Part B providers, with the following among the biggest offenders:

• Subsequent hospital visits. The codes for subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient …) represented $498.3 million in improper payments.
• Initial hospital visits. In the initial hospital visit E/M category (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient …), Medicare made $463.9 million in projected Part B improper payments.
• Emergency department visits. The ED E/M codes (99281-99285, Emergency department visit for the evaluation and management of a patient …) were responsible for $198.5 million in improper payments.
• Hospital visit – critical care. The next code series with incorrect coding error involved critical care visits (99291- +99292, Critical care, evaluation and management of the critically ill or critically injured patient …), logging $134.8 million in projected improper payments.
• As most ED staff members are aware, it’s critical to ensure that you’re reporting your E/M services accurately, since these codes represent a major slice of your ED practice’s income. Particularly in light of the reimbursement losses that many emergency departments have faced due to the COVID-19 pandemic, you want to hang on to as much of your income as you can, and correct coding is the best way to do that.

Resource: To read the full CERT document, visit https://www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0.