ED Coding and Reimbursement Alert

The agency says EDs improperly billed over $315 million to Part B.

Emergency departments are known for putting patient health first, above all other priorities, but CMS is suggesting that perhaps EDs should also dedicate a bit more time to their coding and billing processes. Emergency physicians ranked eighth on CMS' list of specialties with the highest Part B improper payment rates, logging a 12.7 percent rate last year that represented $315.3 million in inappropriate charges.

The backstory: CMS issued its "2017 Medicare Fee-for-Service Supplemental Improper Payment Data" in December 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 10.2 percent improper payment rate among Part B claims during 2017, with the majority of those being classified as overpayments to providers.

Emergency Visit Services Logged Millions in Part B Errors

The government's CERT auditors found other problems beyond the overall 12.7 percent improper payment rate for emergency department practitioners nationwide. Following is a list of problems that CMS discovered in its audit of ED claims:

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 involved overcoding. Many of the errors involved undercoding and underpayments, which meant that these doctors actually deserved more money than they billed. Of course, these types of problems are still considered errors and "incorrect coding," so it would be best to put checks in place to prevent these issues going forward. In addition, the trend of undercoding suggests that the issues may have simply been errors.

Consider the following examples of improperly-coded ED claims so you can avoid a place in CMS' next improper payment report.

Example 1: Suppose your ED physician records a visit with an expanded problem-focused history, a detailed exam, and moderate-complexity medical decision-making (MDM). The coder submits a claim for 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity...).

Is this coded properly? No. If the coder is accustomed to selecting E/M codes in the office or inpatient setting, she might have selected 99285 because she thought that only two out of three elements (history, exam, MDM) were required to select a particular code, but ED coders have to select a code based on all three components, advises Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow and vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

Solution: Therefore, since the documentation in the example featured an expanded problem-focused history and not a detailed one, this claim should have been coded with 99283 instead of 99284. This claim would have been marked as an upcode by an auditor who reviewed it, had it been reported with 99284.

Example 2: A patient reports to the emergency department after hurting her arm playing tennis. She also has diabetes and is in treatment for melanoma. After a level-four E/M service, the physician decides that she has a closed fracture and treats it without manipulation. During the visit, the EDphysician calls two other specialists to discuss treatment options to ensure compliance with the patient's comorbid conditions. The EHR says that the time spent on the visit overall lasted 25 minutes, and the EHR calculator suggests a 99285.

Is this coded properly? No. Just because the physician spent 25 minutes on the visit doesn't mean you can bump the code up to the next level. ED codes do not include time as a descriptive component of E/M services, CPT^® states, "because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time."

Solution: Because the doctor documented a level four E/M visit, you should have reported 99284 and not 99285 in this instance. Auditors would have counted this as an upcode.

Resource: To read the full CERT document, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2017-Medicare-FFS-Improper-Payment.pdf.