ED Coding and Reimbursement Alert

Payers will give high-level E/Ms a closer look, experts say

There is some potentially bad news for ED coders: Based on evidence from a just-released poll, claims reporting level-four and level-five evaluation and management services could be examined even further under the payer's microscope.

Why? A recent survey by American Hospital Directory showed that E/M levels in the ED increased in the past few years.

For example, 24 percent of ED E/M visits were level four (99284, Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity) in 2004.

In 2002, only 20 percent of these services were level four. Experts offer these tips for dealing with an E/M audit in your ED:

Check if You-re an -Outlier-

When a payer is deciding which EDs to audit, it will go after billing outliers first. When looking for outliers, insurers check E/M coding patterns. If an ED's coding falls outside the payer's normal coding patterns, it is a potential audit target.
 
But even an outlier audit is not a signal to start panicking. Outlier status does not necessarily equal outlaw status with payers, said Stephanie Jones, NR-CMA, NR-CAHA, CPC, vice president of operations at Aztec Medical Systems in Miami during a recent Coding Institute teleconference.

-If your office is an outlier, it does not necessarily mean that you are billing improperly. But if you are an outlier, you must make sure your coding is accurate,- Jones said.

Consider this anecdote from Dennis Mihale, MD, chief executive officer of Parses, a claims auditing company in south Florida: Auditors identified a surgeon as an outlier because -his billing seemed to indicate that every patient he treated was in a train wreck.-

However, it turned out that he was a trauma surgeon, Mihale says. So, in this case, the surgeon's billing was entirely correct and legal.

If a medical practice treats lots of high-risk patients, as EDs sometimes do, it will probably use more high-level E/M codes. Just make sure that your E/Ms are all coded at the proper level, especially if you-re filing lots of level-four and -five E/M services.

In the ED setting, predictors of right-shifted E/M distributions (i.e., more patients needing level-four or -five service) correlate with patient acuity -- in other words, EDs with high admission rates, urban settings, trauma designations, or referral centers will tend to have higher E/M levels on average, says Michael A. Granovsky, MD, CPC FACEP, vice president of MRSI, an ED coding and billing company in Stoneham, Mass.

Make Sure Auditor Understands ED Coding

There are a few important differences between E/M services in the ED and elsewhere, and whoever is auditing your ED must understand those differences, says David McKenzie, CAE, director of reimbursement with the American College of Emergency Physicians.

Why is ED E/M coding different? For one thing, there's no distinction between new and existing patients in the ED. Also, you choose the level of service in the ED based on the presenting problem, not the final diagnosis. Consider this example: A patient shows up with chest pain, shortness of breath, and a family history of heart disease. The ED doctor has to assume it's a heart attack and act accordingly -- even if it turns out the patient's final diagnosis is gastritis, McKenzie says.

The final diagnosis (gastritis) would not support the diagnostic studies ordered to rule out a heart attack, such as chest x-ray, EKG and labs including cardiac enzymes. However, the initial presentation is what drives the physician's medical decision-making and provides the medical necessity for the testing.
 
It may take a while for lab tests to come back and reveal the absence of cardiac problems. But meanwhile, the ED physician treats what is indicated by the patient's complaints and the symptoms noted on arrival (possible heart attack).
 
You also need to make sure there is an -apples-to- apples- comparison of the frequency distributions if the audit is triggered based on being an outlier with a model distribution.

Do this: Make sure the distribution is for emergency physicians rather than all physicians, and if possible ask for a comparison with a distribution by payer in your state as opposed to a national average.

Why? There can be significant regional differences in frequency distributions, McKenzie says. (The Medicare distributions for all 50 states are on the ACEP Web site at www.acep.org.)

Watch Out for These Other Problems

There are a few other practices that might lead ED E/M auditors to your facility:

- Your ED physicians may be using -cloned- documentation that has no individuality, which will prick up payers- ears, says Sandra Soerries, director of coding and compliance with Department B in Kansas City, Mo.

- Also, check that your doctor isn't using the same diagnosis codes for every patient. And if you have an E/M documentation template, make sure your physicians are using it properly.
 
Higher Levels Caused by Sicker Patients

Of course, high E/M levels in the ED may just be a sign of the times; over the years, the acuity of patients presenting to the ED has increased.
 
Reality: -We are seeing sicker patients with more complex medical problems. Clinically these patients are requiring more extensive workups. From a coding perspective, this translates into higher E/M levels,- Granovsky says.