Medicare Compliance & Reimbursement

Location may be a factor in higher levels of emergency department claims.

Are you curious about how your practice compares to those of other clinicians in your specialty? A new Comparative Billing Report (CBR) from Palmetto GBA has the details to help you measure your stats against those of other providers nationwide, particularly when it comes to reporting high-level E/M codes in the emergency department (ED).

Background: In its recently released CBR, Part B MAC Palmetto GBA focused on claims issues, trends, and benchmarks that the payer has seen for Medicare providers who bill emergency medicine codes, particularly CPT^® code 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components ...) and modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Palmetto initiated the analysis "because costs for Medicare emergency department services are increasing," the CBR report said in its "Frequently Asked Questions" section. "According to an Office of Inspector General (OIG) report, billing of lower level emergency department codes is declining while billing of higher level codes is increasing. The OIG determined that from 2001 to 2010, 'Physicians' billing of the highest-level code (99285) rose 21 percent, increasing from 27 to 48 percent.'"

Remember: The feds use CBRs as a tool to offer insight into billing and coding trends across different specialties and healthcare settings. CMS partners with its contractor eGlobalTech to produce the reports, which you can find at www.cbrinfo.net. You can use this timely data from Palmetto GBA's CBRs to see where you stand when it comes to the frequency of billing certain services, codes, or modifiers - and more importantly, utilize these peer measurements to eradicate your practice coding problems.

Take A Look at the Findings

The CBR report "examined the percentage of services billed with CPT^® code 99285, the percentage of services appended with modifier 25, and the average allowed charges for all Medicare Part B services per visit," said eGlobal Tech's Nick Grant during a Dec. 13 webinar on the topic.

Among the findings were wide variations in the concentration of 99285s reported based on the state of practice, said Tamara Canipe, RN, clinical quality management coordinator with Palmetto GBA, during the webinar. "The CBR team is aware that practice patterns may differ for various reasons. Some practitioners have subspecialties or distinctive focuses that are not apparent in our claims data. Other providers may practice in underserved urban or rural areas, or in areas with a higher proportion of sicker Medicare beneficiaries."

In some cases, EDs may be confused about the necessary requirements for reporting 99285. To bill this code, you must have a comprehensive history and exam, as well as medical decision-making of high complexity. If even one of these elements falls short of the comprehensive level, auditors would bump the visit down to a 99284 (or lower), since all three key components are required for ED visits.

Canipe pointed out the differences in the history portions of the two higher-level emergency room E/M codes, as follows:

Of course, history is only one portion of the requirements, but is perhaps a frequently misunderstood element in the ED setting because in most cases, the patient and the physician have never met before, meaning the history can't typically be found elsewhere in the patient's record.

Exception: Remember that in the ED setting, there is an exception to the history component of 99285. "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," CMS says.

"This concept is known as the acuity caveat or the emergency medicine caveat," said Canipe. "This caveat is exclusive to CPT^® code 99285, the highest-level emergency department services, and provides an exception if the provider is unable to obtain the patient's history," she added. Be clear that the patient had a high complexity presenting condition and the reason the comprehensive history and/or physical exam could not be completed.

Therefore, always ensure that you not only have all of the elements of exam and medical decision-making thoroughly documented in your notes, but also that you have met the history element before reporting 99285.

Resource: To read more about the CBR on emergency department claims, visit https://www.cbrinfo.net/node/342.