[This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.]
Having enjoyed numerous conversations over the past few months with industry executives expressing concern with how to prioritize the revenue cycle operations of the ED, I thought I might provide some talking points for ED directors in their next meeting with coding and billing managers to assure that compliance and revenue objectives can be met appropriately.
Top hospital billing and coding issues
Coding and HIM: ICD-10 implementation is the number one priority for nearly every hospital we speak with. It is important that all systems are a go for HIM coders to be able to assign ICD-10 codes for ED services. Be sure systems are tested with related ED ICD-10 codes for all the diagnoses we manage. It is also important to implement parallel coding for all coding professionals assigned to the ED to assure we don’t lose valuable time and revenue through coding errors.
Charge Description Master (CDM): Too many hospitals across the United States have limited listings of ED services in their CDMs. Many do so because the processes necessary to add service codes to the CDMs are too complicated and time consuming. Millions of dollars in revenue are lost each year due to incomplete CDMs or through use of facility-assigned combination codes that include multiple ED services under one CDM code that would be separately billable and payable if identified separately. Clean up of the CDM is essential to assure maximum ED revenue. Services performed in the ED are billable through identification of each unique service with appropriate codes.
Coding Policy for Bundling and Unbundling: Too many issues remain unresolved about which ED services can be billed separately and which must be “bundled” into one all-inclusive service. As a result, many billable services are excluded from billing because of a lack of accurate information about what can be billed separately. For the most part, payers require itemization of services on billing forms. Payer software generally bundles the services that are included in service packages unless appropriate modifiers are assigned by coding staff. Payment is then generated according to internal processing rules. To assure your procedures and services are billed appropriately, assign one individual to monitor payer information about up-to-date requirements for bundling and unbundling. Be sure you review up-to-date codes and descriptors in CPT 2015 and through the Medicare HCPCS unique code listings.
Documentation of Physician Orders: For a nursing service to be billed as part of the ED hospital bill, there must be physician orders and nursing confirmation that the services were actually rendered. Verbal orders that are not documented are not billable. Audit your ED records on a routine basis to assure that only the services that were ordered and performed are actually billed.
Signed Records: Records must be signed by the physician(s) responsible for the services provided. Check to see how many unsigned records there are in your ED, and put in place processes to assure that no records are released for billing until complete and signed. Encourage physicians to review the entire record before signing to be sure all documentation, including macros, voice recognition entries, and templated statements are correct and appropriate.
Documentation of Provider Bedside Time for Critical Care: Under OPPS, the time that can be reported as critical care is the time spent by physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or injured patient. If the physician and hospital staff are simultaneously engaged in this active face-to-face care, the time involved can only be counted once. Documentation of this bedside care presents a challenge for most ED staff who may not understand how this can best be entered into the record. It is imperative that a statement summarizing the bedside care and/or detailed entries into the medical record for each bedside episode of critical care be documented into the record and signed or initialed by the responsible provider.
Infusions and Injections: Start and stop times must be entered by nursing personnel for each infusion in accordance with Medicare policy. Nursing staff must assure that these times are entered accurately in order to facilitate coding of these services. Significant revenue is lost each year from failure of nursing staff to document times accurately.
Top physician billing and coding issues
ED Level of Service and Medical Decision Making: Be sure your coding staff understands how to “score” risk and management options in accordance with your internal policy, with an eye on how your local MAC looks at MDM. The MDM content was developed for all medical specialties and is not specific to emergency medicine, so some interpretation is necessary to assure your coding of MDM reflects the services you provide. Check out the ACEP reimbursement FAQs for help in understanding how MDM works for emergency services.
Billing for EKG Interpretations, Ultrasound, and X-ray Interpretations Performed by EPs: Your group will need to establish a policy to determine documentation requirements for billing of these services. Policy should address: 1) content of the documentation required for categories of interpretations; 2) which payers you will bill these services to; and 3) which physicians are credentialed to provide these services.
Critical Care and Additional Procedures: Critical care requires that documentation identify the critical illness or injury being managed, the critical decisions made, and the time spent by the ED providers to manage the critically ill or injured patient. Documentation often fails to provide the time spent by the ED physician managing these patients. In addition, the “split/shared” visit rules do not apply to timed services. Thus, the time spent by either the physician or the advanced practitioner can be used to support the critical service, but not the elements of time spent by both. Where services provided by teaching physicians with the assistance of residents is concerned, only the time spent by the teaching physician can be used to determine the total time spent. The time spent by residents cannot be used toward meeting the time requirements for critical care.
Some procedures are included in the critical care package, but most are not. Consult the 2015 edition of the CPT manual published by the American Medical Association for a listing of these procedures.
Template, Voice Recognition, and Cloned Documentation: More and more payer audits are identifying cloned documentation that is used on many, if not all, patients. When it comes to compliance, this is a high-risk practice. Documentation must be individualized for each patient. Macros are OK as long as they are pertinent to specific findings for individual patients. Voice recognition can create significant problems as well.
Take a look at these actual medical record entries via voice recognition that were not modified by the emergency physician:
- ED Course: Patient was seen and evaluated. Secondary to his recent trauma as well as his cardiac history, a workup was performed. An EKG was performed that showed a sinus rhythm at a rate of 61 beats per min and PR interval is 224 and consistent with a first-degree AV block. Uterus is 98 QTC 398.
- He bought something left in the store and Nexium remembers was laying on the ground with bystanders picking him up. Patient denied any chest pain, shortness of breath, headache prior to the episode.
- History of Present Illness (HPI): Patient is a 3-year-old male who presents to the emergency department with increased weakness. Patient lives at an assisted care facility.
- Consultant did present to the ED and interrogated the patient.
- He does have an ileostomy bag and has been scratching and removing the bags that are attached. Per family members present, the patient has removed multiple plagues on a regular basis and needs himself with stool all over.
Lesson to be learned? Keep a close eye on the performance of all processes in your ED to assure you are minimizing compliance risk and generating revenue from accurate billing of all services.