ED Coding and Reimbursement Alert

Few healthcare providers are in more of a reimbursement crunch than emergency physicians: Medicare and many commercial third-party payers are cutting reimbursement levels, managed-care plans often strenuously attempt to limit their insured members ED visits, and, as always, the hospital emergency room must absorb the cost of a large portion of unpaid care for indigent patients.

In this climate, ED physician groups can hardly afford to leave any earned revenue uncollected, but emergency medicine management consultants and billing experts often tell us that emergency physicians frequently leave valid charges on the table due to errors in coding and documentation.

What are the most commonly missed reimbursement opportunities in the emergency department? To find out, ECA interviewed two coding and billing consultants who regularly perform internal coding audits for emergency physician staffing groups: Randy Thompson, CPC, coding consultant with Healthcare Consultants of America, Inc., in Augusta, GA, and Susan Callaway-Stradley, CPC, a former hospital and emergency department coder who is now an independent coding consultant and educator based in Charleston, SC, and was recently named as AAPCs coder of the year.

The five areas to watch out for according to Thompson and Callaway-Stradley are:

1. Under-reporting the evaluation and management (E/M) level for ED visits. Both Callaway-Stradley and Thompson report that many ED physicians are unfamiliar with the methodology for coding E/M services (99281-99285). As a result, they often report the level of service based on a vague impression of how difficult the physician felt the treatment decision was to make. For example, Callaway-Stradley relates, many physicians feel that any visit to the ED that involves the treatment of a cold should warrant no more than a Level 2 (99282) ED service code.

They may see someone with an upper respiratory infection who presents with a fever and some potentially severe side effects and still feel that it is a Level 2 service, because the diagnosis was readily apparent to them and did not take a long time to make, she continues. A seasoned physician may not take a long time making this diagnosis, but a young doctor might.

Frequently, the problem is not a lack of documentation, but the failure of the physician or person who assigns the visit code to fully credit all of the available information.

Many times, they document the visit correctly, Thompson says. They just dont select the appropriate code for that service. When I go back and review records and look at the presenting problems and similar items, I often find a lot of money left on the table, she adds.

2. Not including sufficient documentation of wound repairs. Physicians may document a visit adequately, but they often omit needed information when reporting procedures, Thompson relates.

For example, he has noticed that ED codes often do not include the length of a laceration in the patients chart. This can result in the selection of a lower-level wound repair code than would be justified by the service performed.

I see a lot of these procedures reported with 12001 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet] 2.5 cm or less) when they probably should have been reported with a higher-level code, Callaway- Stradley confirms.

Physicians must remember to document the following:

1. length of the laceration;

2. whether the repair was simple, intermediate, or
complex, according to the CPT definitions; and

3. whether any extensive decontamination or
debridement of the wound is necessary.

There are several different codes for simple wound repair that vary based on the length of the laceration, Thompson emphasizes.

For example, a simple laceration of the arm that is between 2.6 cm to 7.5 cm should be reported with code 12002, which has a higher relative value than 12001. But, if the length is not documented, the coder has no choice but to assign the lowest level code.

And, if the physician performed a complex repair of a
4-cm laceration, the code for that (13121) is worth 10 times the amount for a 12002the code for a 4 cm simple repair, Callaway-Stradley says.

Documentation of the performance of extensive
decontamination or debridement of a wound can also net added reimbursement.

For example, the physician may perform a simple laceration repair, but there was glass in the wound and he or she had to spend 30 minutes picking shards of glass before closure. It is not the same treatment as a simple repair, where they cleanse it, ensure that there are no foreign bodies present and close the wound, she explains. CPT states that single-layer closure of a wound that requires extensive cleansing or removal of particulate matter constitutes intermediate repair instead of a simple one.

Extensive debridement of a wound, prior to repair, should often be reported separately with another code in addition to the code for the repair.

Note: See guidelines for Repair (Closure) listed in the Surgery section of CPT under the Integumentary System.

3. Failure to document who performed intubation or CPR. Many ED physicians are unaware that in certain circumstances the performance of cardiopulmonary resuscitation (CPR, 92950), or intubation (31500) is separately reportable, and therefore do not document who performed the procedure. And if the person who performed the procedure isnt documented, then it cant be reported, Thompson advises.

Callaway-Stradley cautions that many payers consider CPR to be included in critical care services. So, if critical care codes are reported for a patient, the CPR cannot be reported separately.

However, you have some instances in which CPR is performed and the length of time does not reach 30 minutes (the minimum length of time for reporting a critical care code), she says. In this case, the performance of CPR should be reported along with the other service codes.

Also, not all intubations should be reported, Callaway-Stradley feels. Report only those instances when emergency intubations are performed by the physician to help the patient breathe, not every time someone puts in a tube, she adds. Documentation of the procedure must also support that the ED physician performed the tube placement.

4. Not reporting ECG or x-ray interpretations. This is a controversial area for many ED groups. The hospital often has contracts with radiologists or cardiologists to do x-ray or electrocardiogram (ECG) interpretations (93000, routine ECG with at least 12 leads, with an interpretation and report; 93010, interpretation and report only). However, these reads are usually the day after the ED visit or even two days later, and are often a quality assurance measure instituted by the hospital, he says.

For the purposes of an ED visit, Medicare has stated it will pay for the interpretation and report that directly contributed to the diagnosis and treatment of the patient, Thompson notes.

In negotiating an ED groups contract with a hospital, he recommends pointing out the Medicare intermediaries base payments to the hospital on the costs that the facility incurs for treating patients.

If the hospital wants to have specialists do the interpretations and seek reimbursement for their costs, then that is a separate issue from the Part B carrier paying for the test interpretations that led to the patients treatment, he believes.

Note: X-ray interpretations are reported by choosing the code for the x-ray performed and attaching the -26 modifier (professional component) to indicate that only the professional service (the interpretation) was performed by the ED physician. The x-ray codes are listed in the radiology section of CPT, under each body area. An example would be the interpretation of a chest x-ray, two views, frontal and lateral, which would be coded as 71020-26.

5. Reporting critical care and a separate E/M code. Many ED groups are not reporting emergency service E/M codes when critical care is also performed on the same patient on the same day, when in some circumstances, they can, Thompson believes.

If the patient presented to the ED with chest pain and the physician performed a complete workup, and then the patient unexpectedly went into cardiac arrest requiring critical care, then both an E/M code and a critical care code could be reported, he says.

Note: Critical care codes can only be reported if the time spent on critical care exceeds 30 minutes.

To support this contention, Thompson cites a 1992 memorandum to Medicare carriers advising that, if a patient requires critical care services upon presentation to the department, a separate E/M service cannot be billed for that day.

Thompson interprets this to mean that, as long as the patient did not initially require critical care, but only required critical care after receiving an initial workup, then both services can be reported separately.

Callaway-Stradley, however, advises caution when reporting critical care and a separate E/M code on the
same day.

I would only consider it valid when there are two separate sessionssuch as a patient presenting in the morning with a minor injury, is treated and released, and then returns later that day in need of critical care, Callaway-Stradley says.

The two sessions need to be separated by time and, usually, by presenting complaint, she adds. You should only do it in a situation where you feel comfortable that these services are unrelated, Callaway-Stradley says.

Capturing Legitimate Revenue Doesnt Always Mean More Revenue

Thompson emphasizes that while many groups he evaluates are losing money because they miss opportunities to collect appropriate charges, some groups are reporting charges inappropriately and are putting their practices at risk for an even more significant financial crunchthose of fraud and abuse fines and penalties.

I have recently done an audit for one group that has left almost $800,000 per year on the table. But, I also have seen a group that is $90,000 ahead of the game because they like to select Level 5 E/M codes for almost everything they do. They are facing some significant liability, he states. The emphasis has to be on reporting the services appropriately, not just on reporting all of the codes you possibly can.