ED Coding and Reimbursement Alert

National Part B overall error rate is only 8.6 percent, the agency notes.

Emergency departments are well known for seeing a wide variety of diagnoses on any given day, which can make coding a challenge, since there aren’t any set expectations of what types of patient conditions you’ll see. That has potentially caused confusion in coding ED visits — at least that appears to be the case based on CMS’ most recent report.

The backstory: CMS issued its “2019 Medicare Fee-for-Service Supplemental Improper Payment Data” on December 18 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 improperly paid charges. Overall, the government found an 8.6 percent improper payment rate among Part B claims during 2019.

Emergency Visits Logged Millions in Part B Errors

On the list of the services with the most Part B improper payments, CMS ranks emergency room visits high, logging an 11.7 percent error rate, totaling over $290 million in improper payments. The majority of those errors (83 percent) were due to incorrect coding, while another 13.2 percent occurred because of insufficient documentation.

The insufficient documentation statistic may be particularly concerning to EDs, since that error rate was just 5.8 percent last year. That 7.4 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 more than three percentage points higher than the overall Part B error rate of 8.6 percent.

Avoid These Common Errors

Although many practices 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, about $24 million of ED visits were incorrectly paid due to downcoding — in particular, 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components…) alone had a 10 percent underpayment rate, which led to $17.7 million in underpayments.

On the flip side, some $2 billion Part B payments were incorrectly paid due to upcoding errors. In particular, 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components…) logged a 13.8 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, with an improper payment rate of 9.7 percent.

When ranked among all E/M codes, ED visit code 99285 ranked fifth for most incorrect payments with its 13.8 percent improper payment rate. It was topped by established patient office visit codes 99213 and 99214 and inpatient care codes 99223 (initial) and 99233 (subsequent).

Are You Upcoding ED Visits?

With $211 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 established outpatient E/M codes 99211-99215 (which only require two of the three), and coders who are accustomed to other specialties tend to forget that all three requirements are necessary.

If an auditor reviews your note, they want to see “documentation of the physician’s thought process, the differential diagnosis/risk factors considered, results of workup, and plan of care required to treat the patient,” says Terri Tamez, CPC, CEO of Phoenix Coding and Consulting Service. “If you document a comprehensive history and physical but fail to document your cognitive efforts, you may be missing an opportunity to assign the most appropriate code for the services provided. Payers are looking for this lack of detail to deny high level claims. Remember — if it is not documented, it didn’t happen!”

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 noted five elements in the notes.

Don’t Forget This Caveat

According to CMS guidelines, “If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.” Part B MAC Palmetto GBA issued a tip in July 2019 noting that to use this caveat, the documentation must clearly reflect:

• The components that were unobtainable (HPI, review of systems, or past/family/social history)
• Circumstances that preclude obtaining these elements (dementia, sedated on a vent, etc.)
• Attempt to obtain from other resources:

            o A family member, spouse, nurse, etc., was not present or was unable to provide additional information
            o The medical record (chart, ambulance run sheet, etc.) did not contain the information needed

If patient or family can provide information at a later time during the ED encounter, the provider may add an addendum containing this information.

The CMS documentation guidelines allow the general “history caveat” mentioned above to any E/M code. If you’re in the ED with this situation with a high severity patient, CPT^® allows you to invoke what’s known as the “acuity caveat” and subsequently report 99285, assuming you’ve met all other elements for this code. The language appears in the CPT^® descriptor for 99285 and reads, “requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status.” Note that the acuity caveat can apply to history, physical exam, and potentially even to medical decision making (MDM) if the urgency of the presentation would prevent additional diagnostic testing or taking time to review old records or consulting another provider before the patient is transferred to surgery or expires. Be clear that the patient had a high complexity presenting condition and the reason the comprehensive history could not be completed.

“There are instances where a patient may present as a trauma or with a life-threatening condition and may be considered an ‘acuity caveat,’” says Erin Edwards, CPC, coder with RevMD. “If this is the case, the patient may be unresponsive or mentally and/or physically unable to provide information.”

To ensure that you meet the criteria for using the caveat, the physician should clearly document in the medical record the circumstances which precluded obtaining this information or from doing the comprehensive examination, Edwards says. “This documentation shows a good faith effort on the part of the physician.” She offers the following possible examples of terms that could indicate a caveat if they appear in the notes:

• Unresponsive
• History unobtainable
• History obtained by family member due to altered mental status
• Comatose
• Aphasic
• Obtunded
• Paralyzed
• Intubated

Resource: To read the full CERT document, visit cms.hhs.gov/cert and click “CERT Reports” on the left side of the page. From there, you can download the 2019 report.