From the trenches — finding lost ED revenue
This is the first of a two-part series on recovering lost ED revenue
[This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.]
There are many ways an ED practice can lose revenue. Today’s complex medical payment systems require constant monitoring and analysis to stay ahead. Without a flexible data management tool/dashboard to identify outliers and compare provider productivity and quality, it may be difficult to manage your ED appropriately. However, while you determine the best approach to overhauling your ED coding and revenue management processes, here are a few quick things you can do to determine whether you will need a deep dive or surface look at how your ED is performing.
Infusions and injections
Emergency departments can easily lose in excess of $1 million when start and stop times for ED nursing infusions aren’t documented by nursing staff. Sounds like an easy fix, right? But depending on the EMR system you are using to capture nursing services, it may not be as easy as it looks to assure each infusion start and stop time is addressed via ED documentation.
First, physician orders must be clearly stated in the record in an easy-to-identify orders section. Some EMRs permit physicians to enter free text anywhere on the chart, so it’s not unlikely to find bits and pieces of orders buried in sections other than the "orders" section of the record. Second, nurses need in-service in order to understand to which procedures they need to apply start and stop times. All infusions are not created equally. Piggy-backs with multiple meds, hydration, and multiple lines all require a detailed understanding of how the start and stop times are used to assign the billing codes.
In the ED, the highest hierarchy or priority code determines which service is primary and which is secondary. Infusions are primary to injections and both are primary to hydration. Although chemotherapy doesn’t apply in the ED, it still is considered the highest priority/hierarchy of the infusion/injection services. However, we are not including these valuable services in our discussion of ED services.
Assume a patient receives a normal saline infusion, an antibiotic infusion (not concurrent), and an IV push during the same episode of care, all in the same vein. The category for the initial code will be from the injections/infusions category, which is primary to the hydration category. Then within the injections/infusions category, the nurse would identify the antibiotic infusion as the initial code because infusions are primary to pushes. The hydration code would be considered an add-on service and not an initial service. Only one initial code may be used per encounter per vein. In order to bill these appropriately, as each is a timed service, the start and stop time of each must be documented. Without this documentation, the infusions would be classified as an IV push, which is a significant loss of revenue.
Facilities often fail to clearly identify and/or code for the services that qualify for critical care. Critical care is a timed service and in the ED setting it requires summarization of the bedside time spent by clinical providers as required by CMS/Medicare. Without that documentation, critical care is downgraded to an Evaluation and Management level (99281-99285) according to each individual ED’s facility Evaluation and Management (E/M) criteria. This results in significant lost revenue.
In addition, for those facilities that bill Trauma Activation, the Trauma Activation service would be billable, as it must be billed in addition to Critical Care (99291) for qualify for payment. To remedy any problems you may be experiencing with appropriate assignment of critical care, consider adding a field to your EMR that requires nursing to summarize bedside time spent providing critical care to your ED patient. In addition, be sure coders all recognize the content of critical care by providing a table of critical interventions, drugs, procedures, and presenting problems (PP)/diagnoses that indicate critical care has been provided. Audit frequently to identify any areas where coding staff and clinical staff disagree on content of the critical care service.
Emergency departments provide significantly more critical care than is actually billed out to payers, and now is a good time to begin the process of correcting any errors. Emergency department acuity data is critical to understanding appropriate ED staffing, acuity mix, and cost of providing services. If critical care is not captured appropriately, your ED acuity will be flawed. Most, if not all, of this data generally comes from the coding process, so it must be accurate and capture services appropriately.
Increasing payer denials are being generated from medical necessity audits. Although the work may be appropriately documented, the reason for it can be subjectively judged as "not medically necessary" by payer auditors who do not fully understand the "what and why" of ED care. When appealing these claims, the volume of which is climbing significantly, your ED must connect the dots from the chief complaint/presenting problem (PP) through the identification and acuity of risk factors to the overall medical decision-making process in order to justify the service. Be cautious of EMR systems that provide a drop-down menu to assign the CC/PP as they are generally not nearly as inclusive as required to address the intricate details of a patient’s complaint.
Recording the patient’s own words, followed by the information provided by the clinical provider upon questioning is the best combination of information to support the services that are provided. Providers should be careful to list differential diagnoses as well, as they provide support for the tests and interventions. Differential diagnoses can underscore the range of problems being considered, but generally require documentation of additional testing to rule out the problem list. The differentials should be correlated to the diagnostic studies in order to be effective for determining medical necessity.
Evaluation and management (E/M) distribution/acuity
Closely monitor how your evaluation and management criteria are performing by monitoring the ED evaluation and management distribution for your facility. If the majority of your patients are falling into ED levels 1-3 (99281-99283), you may want to have an outside auditing firm take a look. ED acuity is on the increase as more and more patients are moved to outpatient settings, and have no primary provider and/or insurance. So, be sure you are assigning the ED service levels accurately. This is an area that can result in significant financial losses to your institution. Medicare permits each hospital to design its acuity criteria individually, so yours should accurately reflect the type of services you provide as well as demonstrate the acuity managed in your ED.