ED Coding Update

You can optimize revenues, compliance

[This quarterly column on coding in the ED is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, president of Edelberg Compliance Associates, Baton Rouge, LA. If there are coding issues you would like to see addressed in this column, contact Edelberg at phone: (225) 454-0154. E-fax: (225) 612-6904. E-mail: caral@cedelbergcompliance.com.]

Much has been written about the best practices for increasing ED revenue in such a compliance-driven, audit-rich environment. However, there are still many opportunities to maximize revenue and compliance, particularly as ED volumes and acuity continue to increase. Maximizing revenue requires focus on documentation, codes, charges, and revenue cycle management. Perfecting one without attention to the others prevents achieving revenue goals.

Consider the following for your compliance/revenue improvement program in 2011:

• Use medical decision making (MDM) as an indicator of documentation improvement.

Identify how many records are down-coded to levels lower than the level of MDM. As MDM is a true indicator of ED professional acuity, any evaluation and management (E/M) coded lower than the MDM level is an indication that your ED providers need inservice on the required elements of history and physical examination.

• Initiate documentation reporting for your providers.

Although you might be closely monitoring your physicians and mid-level providers for documentation omissions, few facilities track nursing documentation problems. Omissions of nursing documentation of repeat assessments, orders, and times procedures (critical care, observation, infusions, and injections) can cost hospitals hundreds of thousands of dollars in lost revenue. Design a tracking and report system for nurses to elicit their support in documentation improvement.

• Compare your ED professional acuity distribution to your facility acuity distribution.

If the facility distribution doesn't meet or exceed the professional distribution, you might need to step back and re-evaluate the criteria you are using to assign facility levels. Facility E/M levels include resources of ED staff used to support the ED physician as well as consultants who come to the ED. The consultant support might be significant but not recognized by your facility assessment criteria.

• Ensure correct billing of ED procedures.

Can you be sure all procedures performed in the ED are listed on your facility chargemaster? Frequently missed procedures include complex laceration repairs, orthopedic procedures, foreign body removals, burn management, and incision and drainage. How can you ensure you are capturing them? Compare billing of these services between the ED providers and the hospital. If ED physicians are billing more procedures than the hospital, something is amiss, and it might be costing you significant revenue. The facility should be billing the same number of surgical procedures billed by the ED MDs, in addition to infusions, injections, and other services performed by consultants.

• Review your ED fees.

Do your charges meet or exceed the Medicare payment amounts? Have you checked to be sure your charges meet or exceed other contracted payer fee schedules? Your charges should, at the very least, meet contracted fee amounts.

• Are you using mid-level providers in your ED?

The rules for documentation and supervision differ between Medicare, Medicaid, and private payers and might differ for certain types of services. It's a good idea to revisit these rules to be sure your documentation supports the services of the supervising physician and to ensure your billing is being performed correctly. Medicare requires personal involvement of the "supervising" physician to support billing by the physician. If no personal involvement is documented, Medicare pays only 85% of the Medicare Fee Schedule. From a compliance perspective, you need to ensure coding accurately reflects who performed what! (Improved documentation can sometimes create new challenges. See Edelberg's column, below.)

Differentiate your coding levels

More tips for revenue enhancement

By Caral Edelberg, CPC, CCS-P, CHC
Edelberg Compliance Associates
Baton Rouge, LA

As a specialty, emergency physicians have vastly improved documentation. As a result, the intention of the Centers for Medicare and Medicaid Services to differentiate 99284 "moderate" medical decision making (MDM) from 99283 "moderate decision making" by the level of history and physical examination no longer works!

The vast majority of ED records score out at the 99284 moderate decision making level, and with history and physical examination at detailed (99284) or comprehensive (99285) levels, you might be coding too many 99284s. Remember that medical necessity still counts. Consider differentiating your 99283 MDM from 99284 MDM with the combination of the presenting problem(s) and the interventions documented during the ED course. This should help to determine which level of moderate MDM you provided.

Here are some other recommended revenue enhancement techniques:

• Closely monitor revenue when transitioning from your dictated/template medical record to an electronic format.

Services performed with inaccurate or incomplete documentation cannot be billed. These services include procedures without orders and orders performed by nurses but not documented. The combination of the two account for significant losses but can be easily corrected with a tracking and documentation improvement program.

• Are your bills going out quickly and with correct information? Are the units of each service billed correctly?

Make sure coding audits are performed with a review of codes and additional areas of the claim form that often result in denials. If you can't list the top five reasons for denials in your practice or hospital ED billing, you can guarantee your revenue is compromised.

• When was the last time you saw a report that scored each of the areas we have discussed here?

Do you routinely receive a report for your practice or ED department that lists documentation deficiencies, frequent coding problems, chargemaster problems and resolutions, and frequent denials by percent of total claims? If you have to request special programming each time one of these problems are identified, chances are you aren't able to analyze and address issues fast enough. Consider designing a summary that tracks key issues on a monthly basis.