ED coding patterns and EMRs draw attention to the potential for upcoding
[This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates,Baton Rouge, LA.]
Coding patterns for emergency services have been scrutinized in the press recently. The New York Times published an article on August 14, 2012, detailing the extraordinary profits being earned by the health care industry giant HCA. In the article, HCA is lauded for its successful 20% ED growth from 2007-2011, while during part of this time it was under Medicare scrutiny from its Medicare fraud settlement and operating under a corporate integrity agreement.
Just prior to the conclusion of the governmental oversight period in 2008, HCA instituted its new emergency department coding system, based on the American College of Emergency Physicians facility coding guidelines. By 2010, HCA saw an increase it its two highest ED facility levels, which had increased up to 76% of total emergency department payments, while other hospitals were experiencing only 74% of their payments from these top two emergency department levels.
The overall impact of these coding improvements increased HCA's adjusted earnings by 7% in a single quarter, resulting in a $75-$100 million increase in earnings from ED coding revisions. No additional detail is provided to address whether or not these patients were admitted or discharged, which specific codes accounted for the increase in revenues, or whether or not there was any change in ED acuity. It is known that at the same time HCA was improving their coding system, they instituted controls to reduce the number of patients who did not seem to have a true medical emergency and were unable or unwilling to pay for emergency services.
Unrelated to the HCA article, Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius warned hospitals that the Obama administration will not accept attempts to "game the system" by using electronic health records (EHRs) to boost Medicare and Medicaid payments. Holder and Sebelius issued the warnings in a strongly worded letter sent to the American Hospital Association (AHA), Association of Academic Health Centers, Association of American Medical Colleges, Federation of American Hospitals, and National Association of Public Hospitals and Health Systems.
The letter stated that there is evidence that hospitals are using EHRs to obtain payment for which they are not qualified, a process known as "upcoding." Two recent reports found that EHRs are pushing up the cost of care, not saving money as they were expected to do.
Among the investigation's key findings:
• Doctors steadily billed Medicare for longer and more complex office visits between 2001 and the end of the decade, even though there's little hard evidence they spent more time with patients or that their patients were sicker and required more complicated — and time-consuming — care. The higher codes for routine office visits alone cost taxpayers an estimated $6.6 billion over the decade.
• More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials say such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that.
• The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials say they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of EHRs and billing software.
• Medicare administrators have struggled for more than a decade to crack down on medical coding errors and abuses, often in the face of opposition from medical groups, including the American Medical Association, which helped design, and now controls, the codes. Whether they make honest mistakes or engage in willful misconduct, there's little chance doctors who pad their charges will face any serious penalties.
How can emergency physicians assure that all essential medical information is recorded for both clinical and billing purposes while avoiding the use of template statements and phrases? First and foremost, template statements that appear on all medical records in the same verbiage are a clear indication that the system, not a provider, formatted the information. Payer auditors look for the same statements on every patient, whether or not they are pertinent to the care given, as clear indicators of EHR formatting of statements.
Although medical decision making (MDM) is a strong indicator of the medical necessity for treatment, elements of MDM used for coding purposes can be subjective. This leads many Medicare Administrative Contractors (MACs) to revise the documentation guidelines published by CMS and AHA and has resulted in regional differences in how documentation can be "scored" to develop a billing code. This has further created wide regional variances in how ED codes are billed to Medicare.
Methods to consider that may help avoid "over-documenting" elements resulting in higher code levels that might be considered "upcoding" include:
1. Addressing risk factors pertinent to each visit and elaborating on those related systems.
2. Addressing history of present illness (HPI) in a separate notation from the review of symptoms (ROS). Assuring that problems documented in the HPI are expanded into pertinent positives and negatives in the ROS for all related systems. Some Medicare MACs require a statement about each system in order to qualify for the higher E/M levels so "all systems reviewed and negative unless otherwise notes" may not be acceptable.
3. Checking the website for your local Medicare MAC and reviewing their documentation guidelines and audit forms. This is where you can learn how your records will fare in a Medicare audit.
4. Remembering to include pertinent differential diagnoses to support testing and interventions where appropriate.
5. Assuring that statements are pertinent to the patient. Female gynecologic system reviews on male patients, and smoking and street drug use statements on pediatric patients are two areas that frequently present problems on review.
For hospitals using the same EHRs to assign facility levels, facility coding criteria should be developed to assure the following principles are addressed:
- Coding guidelines for emergency and clinic visits should be based on emergency department or clinic facility resource use, not physician resource use;
- Coding guidelines should be clear, facilitate accurate payment, be usable for compliance purposes and audits, and meet HIPAA requirements;
- Coding guidelines should only require documentation that is clinically necessary for patient care. Preferably coding guidelines should be based on current hospital documentation requirements;
- Coding guidelines should not facilitate upcoding or gaming;
- Coding guidelines should exclude any services or resources that were "separately billable" by the hospital;
- Coding guidelines should be usable by all health care payers.
Few data are available to track emergency department facility acuity distribution nationally. However, Medicare continues to reference in its OPPS final rule that hospitals continue to demonstrate a reasonable acuity distribution for emergency departments.