ED Coding and Reimbursement Alert

Emergency department practitioners exceed the national improper payment rate.

Your emergency department is probably active and bustling every day, but it’s possible that with all that activity, correct coding could be falling through the cracks. ED practices logged higher error rates than the general Part B population, according to the latest report from CMS.

The backstory:  CMS issued its “2018 Medicare Fee-for-Service Supplemental Improper Payment Data” on November 30 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 an 8.1 percent improper payment rate among Part B claims during 2018.

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 11.3 percent error rate, totaling over $238 million in improper payments. The majority of those errors (94.2 percent) were due to incorrect coding, while another 5.8 percent occurred because of insufficient documentation.

This makes the ED visit error rate more than three percent higher than the overall Part B error rate of 8.1 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 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.

The stats: According to the report, about $10 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 6.3 percent underpayment rate.

On the flip side, some $214 million in 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 14 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 14.2 percent.

When ranked among all E/M codes, ED visit code 99285 ranked fourth for most incorrect payments with its 12.4 percent improper payment rate. It was topped only by office visit codes 99214 and 99213 and subsequent hospital care code 99233.

Are You Downcoding ED Visits?

With $10 million in ED visits being undercoded -- much of it involving 99283 -- you may be wondering if your practice makes up part of that number. Check out these quick tips to ensure that you aren’t shorting your ED’s income.

Know What Differentiates 99283 From 99284

Most EDs report 99283 and 99284 as their most frequently-billed E/M codes, but the line between these code levels can sometimes be hard to distinguish.

The medical decision-making required for both codes is the same: moderate complexity. The technical difference between the two levels of service lies mainly in the level of history taken and the level of physical examination performed by the physician. Whereas 99283 requires the performance of an expanded problem-focused history and physical, 99284 requires a detailed history and physical.

Requirements of History

The first component of any of the emergency service E/M visit is the level of history taken. According to both the 1995 and 1997 guidelines, there are three components to a medical history: history of present illness (HPI) review of systems (ROS), and a past family or social history (PFSH) related to the presenting problem or problems.

For code 99283, only a history of present illness and a brief review of systems are required. However, to report a level four visit, you need at least a brief HPI, an extended ROS (two to nine elements) and at least one element of PFSH.

Examination Requirements

The second component of the E/M level is the physical examination. A 99283 requires an expanded problem-focused examination. According to 1995 documentation guidelines, this level requires documentation of the examination of the affected body area or organ system and at least one related body area or organ system.

According to the 1997 guidelines, which instituted bulleted items on templates for each body area/organ system, the detailed exam must include a general multisystem examination of at least six bulleted items documented or a single organ system examination with documentation of at least six bulleted items.

Medical Decision-Making

The third component of an ED E/M service is the level of medical decision-making (MDM) employed by the physician to establish a diagnosis and determine treatment.

CPT^® documentation guidelines also establish three components of MDM: The number of diagnoses and management options considered, the amount and/or complexity of data reviewed by the provider, and the risk of morbidity or mortality to the patient.

As stated before, both 99283 and 99284 require MDM of moderate complexity. In order to reach an overall level of moderate complexity, two of the three MDM components must meet or exceed a moderate level.

Keep Severity in Mind

CPT^® indicates that for code 99283, the nature of the presenting problems are usually of moderate severity while for code 99284, the presenting problems are usually of high severity. Coders and physicians must consider the level of service justified by the patient complaint when choosing an E/M level to report.

Some doctors just get in the habit of documenting extensively on everything, but it is the coder’s job to then look in the CPT^® book and understand the difference between 99283 and 99284 to determine whether the code justifies the service.

Bottom line: By carefully calculating all three levels involved in the E/M code selection, your ED will avoid accusations of improper coding in future audits.

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/2018MedicareFFSSuplementalImproperPaymentData.pdf.