ED Coding and Reimbursement Alert

Are you under-reporting these common ED services?

Emergency medicine patient volumes, acuity, and charges continue to be in the regulatory spotlight in 2013, which makes it imperative that your ED facility coding and billing elements accurately capture services and bill them correctly. In addition to staying compliant, you’ll also want to be sure you’re not leaving deserved revenue on the table this year.

Good news: Medicare payment levels for 2013 indicate a slight improvement in payments for ED facility visits, as the chart below indicates:

Assess These Areas For Missed Revenue

There are a few things you can do that may give you a revenue opportunity without risking compliance liability, says Caral Edelberg CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, in Baton Rouge, LA.

High acuity nursing: Review and, if necessary, revise your ED nursing levels and the content of each. The higher acuity levels (99284 and 99285) reflect the highest complexity resources you provide. If they aren’t documented and utilized appropriately by nursing, coding and billing staff, you are allowing too much revenue to slip away, Edelberg stresses. Have nurses and coding staff take another look at the services that each level supports, she says.

Check out this list of other areas Edelberg cites as hidden revenue generators:

CT scans, Ultrasounds, Doppler, VQ Scans generally indicate a higher level of acuity for patients whose chief complaint requires a higher level of ED resources. Patients who require these services may qualify for a 99284 or even 99285 level of service based on the medical necessity and additional resources and intensity of services required to manage these patients.

Patients getting IV’s? Although these services are billed separately, they indicate higher acuity and higher resources for the ED. These patients may also potentially qualify for at least the 99284 level of service.

Patient intubated? That’s likely critical care if the additional criteria are met. Did doctors and nurses remember to document time spent bedside with the patient? Critical care for the facility requires bedside time by ED clinical staff and individual staff time cannot overlap; you must subtract time you spend performing other separately billable procedures.

Consultant comes to the ED to treat a fracture or dislocation? The resources necessary to support the service of outside consultants and all that go with it generally qualify for a 99283 or 99284 level of service.

Patient going to observation? Observation can be billed ONLY if the ED service is a 99284, 99285 or Critical Care. Be sure to identify all services to support the patient visit that transitions to observation. Under coding the ED level may result in lost revenue for the observation visit as well.

Patient presents with suicidal ideations and requires nursing observation and additional assessments? Don’t undervalue your nursing observation and assessment services to support patient care and assist family with finding the right solution. Although these patients don’t often get much in the way of identifiable ED interventions (medications, diagnostic tests, and surgical procedures), the time and resources required from nursing staff can be significant. Be sure mental health evaluations and nursing support of the patient and family throughout the ED visit are identified correctly, warns Edelberg.

Review Your Nursing Assessment Criteria

Improperly defined nursing criteria can really affect your observation revenue if you are unable to bill the 99284, 99285 or 99291 required in addition to the observation service. The current CMS observation payment rules require that.the payment for 99285 or 99284 will be combined with the observation and paid as a composite, APC 8003 Observation (Extended Facility Assessment and Management Composite Level II). Observation is then reimbursed at $798.47. Multiply this times the number of times your ED provides treatment at this level and you have a significant financial "reward" for your efforts, says Edelberg.

Remember: Content of each code level determines how each code is billed. If you are under-reporting your higher acuity levels as a result of over-conservative nursing criteria that is too restrictive or being used incorrectly, it is going to affect how you bill observation services as well, she adds.

Pay Attention to These Peds Challenges

Although payment for pediatric patients doesn’t come under the Medicare OPPS guidelines, the special circumstances they present challenge most coding policies. If your ED coding tools are weighted towards interventions and diagnostic studies to determine acuity, you are probably missing a significant amount of the intensity related to pediatric services.

Pediatric patients don’t often receive the high number of diagnostic studies or narcotic IV medications that help to define higher acuity services in adult patients, says Edelberg. But kids bring with them special challenges for emergency department resources. Fevers, urgent problems complicated by long term chronic illnesses under care of other specialists, multiple or continuous nebulizer treatments with little or no improvement in breathing, PO challenge or IV hydration in the ED require significant nursing support through time and intensity of the emergency department service.

Key: Your ED facility assessment criteria should include these unique services that may not be part of the standard adult service line. Neglecting development of a methodology to capture these resource-intensive pediatric services may reduce your ED revenue. Consider taking a closer look at pediatric services and build a system to capture their specialized resources appropriately Edelberg suggests.

Watch for Compliance Risks With Sudden Code Level Changes

Beware of a sudden increase in higher acuity ED visit codes (99284-85 and 99291) without an objective rationale to support your acuity levels, warns Edelberg. Your documentation must support the level of service--the easiest place for an auditor to look and find fault with your coding.

For example: If your physicians and/or nurses are forgetting to identify the amount of time spent performing critical care services and you bill it anyway, you may find payment overturned on audit. EDs provide a much higher volume of critical care than is usually billed because of documentation problems, so Edelberg offers these three reminders:

(1) Be sure it’s documented when performed;

(2) Be sure it’s billed when documented correctly, and

(3) Be sure all agree as to the content of critical care and how it should be documented before payers come calling.

Best practice: If documentation templates are still in use in your ED and they’ve been modified and re-modified over time, create a task force to take another look at your process and content in order to ensure that all of the elements necessary for coding are there and being used correctly by your coding staff. Physician documentation supports professional and technical billing; the better documented services appear, the less likely payers are to recoup payments if services are billed correctly, says Edelberg.