ED frequent flyers and the impact on payment for medically necessary services
[This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.]
With our economy in shambles, and July unemployment at 9.2% nationally just short of the all-time high of 10.81% and way off the mark of the all-time low of 3.31% fewer and fewer ED patients are insured, and it's a significant challenge to manage the resulting uptick in ED visits. Looking at current ED coding and billing audit activity, it seems apparent that payers for those ED patients with insurance are looking closely at medical necessity for the ED visit and focusing on pre-existing conditions to deny or reduce ED payment. Unless the documentation supports the need for the patient's visit, payment for claims may be reduced or denied altogether. It is a common misconception that frequent flyers are abusers of the ED. However, with no other means of healthcare, EDs have become the nation's primary care source for many patients.
How we define ED "frequent flyers" varies from one study to another. The Henry Ford study defined frequent users as patients who visit the ED at least 10 times per year. Excerpts from the Annals of Emergency Medicine indicate that frequent users are those ED patients who are seen four or more times per year. A South Carolina Public Health Institute study defined frequent ED users as patients who visit an ED five or more times per year.
Clearly, there is a significant disparity between how frequent users are defined. However, much of the information that is available indicates that these patients are frequent users because they are in poor physical or behavioral health and lack health care alternatives to the ED.
In 2006, the Annals of Emergency Medicine study determined that "the majority of adults who use the ED frequently (4+ times per year) have insurance and a usual source of care but are more likely than less frequent users to be in poor health and to require medical attention. The February 2011 South Carolina study referenced patients with private insurance as the largest and most quickly growing group of ED users and, yet, according to the national Bureau of Statistics, South Carolina has one of the highest jobless rates in the United States (10.5%), as well as in South Carolina's history. Therefore, it would appear that the majority of our repeat customers have insurance and require our services.
What is medical necessity as it relates to an ED visit? An emergency condition and prudent layperson are defined as, "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (ii) serious impairment of bodily functions; or (iii) serious dysfunction of any bodily organ or part." Payer interpretations of "serious," however, vary, and can make it difficult to support marginally documented ED visits.
Payers generally use the nature of the presenting problem (NOPP) and details relating to medical decision-making to determine whether or not services are medically necessary. Templated documentation systems often prompt high-level history and physical examinations to prevent loss of important details, but are not often used to defend medical necessity unless a number of pertinent positives and negatives are documented. Conflicting documentation (history of present illness [HPI] patient with "shortness of breath and wheezing;" respiratory review of symptoms [ROS] "negative;" respiratory pulmonary embolism [PE] "negative" or not documented) complicates the audit appeal process when medical necessity is the issue under review.
Payers are increasing their review of medical necessity and using deficient documentation to deny claims. Documenting detailed information about the problems patients are experiencing and what is done about them will support medical necessity, particularly for those patients with chronic conditions or low severity NOPPs that, upon investigation, are determined to be more significant problems.
The correlation between a detailed NOPP, strong HPI, differential diagnoses, orders, details about the ED course, and disposition of your patient can protect your revenue in an audit. If you are not using a templated system, use an outline to remind you of what needs to be addressed to support the services you provide. Most important, remember that your charts will be judged by an outsider, not someone familiar with your facility, your handwriting, and your unique abbreviations. Emergency medicine providers should remember to document clear and concise notes and use documentation to support clinical justification for the patient's decision to come to the emergency department for these medically necessary services.
Nature of Presenting Problem (NOPP): Be sure to capture the patient's complete discussion of what brings him or her to the ED. Add some of his or her own words and don't summarize with clinical terminology: Mr. Jones presents today with a chief complaint of generalized fatigue, dizziness, lethargy, and problems concentrating. "I just don't feel right and my legs are weak and my head spins when I get up. I am afraid I will fall. I can't remember when this started but I feel like I'm getting worse."
History of Present Illness (HPI): The history of present illness, as well as medical decision making are significant indicators of medical necessity and are used by payers to determine the appropriateness of the ED visit. Each element of the HPI is important. For each patient, consider and record, as indicated, the location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem.
Differential Diagnoses: Differential diagnoses help to define the problems that are being considered, support the orders for further study or medications, and help other providers, coders, and auditors to understand the significance of the emergency physician's work plan. As long as they are relevant, differential diagnoses are a significant element of medical necessity.
Orders: Physician orders are used to score the complexity of each ED case. Orders for, and interpretations of, diagnostic studies, type and route of medications, comfort measures, and patient monitoring are significant indicators of the complexities of the patient's condition that are being managed during the ED visit.
Overall ED Course: Include a discussion of your thoughts about patients who present with routine complaints, as they are determined to be more significant following study and observation. Think RISK FACTORS and correlate them to the work you are doing to rule out a more significant problem.
Disposition: "I am admitting this patient for further study of _________;" "We will observe the patient's condition and administer ________ for a period of ______ and monitor the results to assure that _________ is resolving or _______ is not present;" "I will discharge this patient and request that he/she schedule an appoint with Dr. Orthopedist for further examination and stabilization of the fracture within 3 days;" " I am transferring this (urgent care)patient to the emergency department for additional care," "I am transferring this patient to the heart center for ________________ and have stabilized for transfer."
If you are audited for medical necessity problems, review your records and appeal each case individually with a narrative to support each of the elements discussed here. Many appeals are successful when a payer better understands the elements of emergency care. Although many payer auditors are unaware of Prudent Layperson and EMTALA, medical necessity is supported by documenting the patient's needs and the rationale for the important services we provide.