ED Coding and Reimbursement Alert

by Caral Edelberg
EDCA Consulting Editor
President
Medical Management Resources, Inc.
Jacksonville, FL

Coders can expect to come under more scrutiny in 99 as a result of the newly released Compliance Program Guidance for Third Party Medical Billing Companies published by the Department of Health and Human Services Office of Inspector General (OIG). These long-awaited recommendations provide a detailed plan for assuring correct coding by coders, appropriate documentation by physicians, and accurate submission of claims and processing of refunds by the billing office. This months column will cover the key issues for ED coders and billing companies that handle emergency services.

Audits and Risk Evaluation

How will the accuracy of your coding be determined? Well, the OIG suggests implementation of a program for self-auditing by either someone within your billing office or by someone outside that is familiar with the coding rules for your area of coding. Emergency medicine is a particularly difficult specialty to code for and its always better to find someone with emergency medicine coding expertise to perform your evaluations.

These self-audits should evaluate your compliance with external payer policies as well as your internal coding and compliance policies and procedures. Coders should have written policies and procedures available to support the coding program and to use as a reference for auditors attempting to evaluate compliance and coding accuracy.

An effective auditing program identifies problems with documentation that may inhibit your ability to code appropriately. The physicians should be audited right along with the coders and receive feedback on how well they are complying with established documentation principles for their group as well as national standards. For example, emergency medicines most frequent challenges often are incomplete documentation of history and physical examination in the formats required for coding of each E/M level, and failure to record ED course and diagnostic interpretations so that coders can identify these services at the correct medical decision-making level.

The time spent in management of the critical patient also presents a significant documentation challenge as ED physicians often neglect to indicate the clinical conditions and time spent in management of the unstable patient to qualify for coding of the critical care services.

Emergency medicine coders often have problems understanding how to identify elements of the history of present illness (HPI) and review of systems (ROS) as separate items; how to differentiate between body area and organ system examinations under the 1995 documentation guideline rules still in force; and when to code an E/M level in addition to a procedure.

Review Claim Denials

The OIG expects to see written procedures and policies in place that specify how the coding department is to comply with proper medical record documentation and payer policies.

ED coding departments should also have a policy in place ensuring that rejected claims are reviewed by another coder in an effort toward reducing errors and identifying problems with payers who refuse to pay emergency medicine claims appropriately.

Written policies and procedures should ensure that coding and billing are based on medical record documentation with emphasis on assignment of appropriate diagnosis codes and use of the documentation guidelines for Medicare Part B claims.

Instituting Spot Checks

A subset of claims coded by each coder should be routinely reviewed as part of a quality assurance programnewer coders should be reviewed more frequently, perhaps weekly, while senior coders should be reviewed less frequently, perhaps monthly. More frequent reviews should occur for claims coded for payers or services identified as high risk. The error rate for each coder should be maintained as part of the compliance documentation as well as for each personnel file for assurance that coding is performed according to established coding policy.

Education and Training Programs

Education and training are included in the OIG compliance plan as one of seven elements of a comprehensive compliance program. Training should include in-house coding workshops, attendance at regional, state and/or national coding educational programs, review of educational materials including newsletters, journals and audio/video tapes of coding information.

Coders should be required to have a minimum number of educational hours per year, as appropriate, as part of their employment responsibilities. For example, the American College of Emergency Physicians presents several coding programs each year and most state ACEP chapters provide at least one program annually discussing state-related payer issues in the coding and reimbursement arena.

Primary compliance training for coders is expected to include: specific government/private payer reimbursement principles governing proper selection and sequencing of diagnoses; improper alterations to documentation; submitting a claim for physician services when rendered by a non-physician (watch out for improper billing of PA or RNP services!); proper documentation of services rendered, including correct application of official coding rules and guidelines; signing a form for the physician without proper authorization and last, but not least; duty to report misconduct.

Monitoring the Providers

With these new OIG recommendations, billing company executives will now be required to monitor the level of accuracy of its billing and turn themselves in to the government if misconduct violates criminal, civil or administrative law. They will also be required to scrutinize emergency physician clients if they identify evidence of misconduct in the form of inaccurate claim submission. If evidence of a providers continued misconduct or flagrant fraudulent or abusive conduct is found, the billing company would be expected to stop billing until the problem is resolved, terminate the contract, and/or report the violation(s) to the appropriate authorities within 60 days of discovery.

Coders, not emergency physicians, do much of emergency medicines coding so this concern may not be relative to your billing environment. However, for those emergency physicians who perform their own coding and have billing done by either the hospital or the independent billing service, they must recognize that they will now come under additional scrutiny by the billing companies they use.

The OIG compliance plan contains many additional recommendations and should be studied in its entirety to assure that your unique environment and concerns are incorporated into your own compliance document. You may obtain your copy from the Inspector Generals website at www.dhhs.gov/progorg/oig/modcomp/thirdparty.htm. In the meantime, begin development of an internal policy and procedure manual if you dont have one. If you do have one, be sure its updated with the latest information on coding for emergency medicine.