ED Coding and Reimbursement Alert

Here are the mistakes that were made - and how you can avoid them.

Emergency department visits are your bread and butter, so you certainly know how to select the correct code every time, right? Not so fast. According to the latest Medicare error rate data, emergency department visits represented over a quarter million dollars in errors last year, logging a 12.4 percent error rate. The vast majority of these claims featured incorrect coding errors, which means that most of the EDs nationwide could benefit from brushing up on their coding skills.

The backstory:  CMS issued its "Appendices for the Medicare Fee-for-Service 2016 Improper Payments Report" in December as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the biggest errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found an 11.7 percent improper payment rate among Part B claims during 2016, with the majority of those being classified as overpayments to providers.

Emergency department coding wasn't immune to the error issues cited by the CERT auditors. In the list of "Top 20 Service Types With Highest Improper Payments: Part B," emergency department visits ranked 11th, with an error rate of 12.4 percent.

Emergency Visit Services Logged Millions in Part B Errors

The government's CERT auditors found other problems beyond the overall 12.4 percent error rate for emergency department visits. Following is a list of problems that CMS discovered in its audit of ED claims:

Make Sure You Don't Hit These Hot Buttons

Keep in mind that although millions of dollars in errors were recorded for ED practices, not all of them involved overcoding. Many of the errors involved downcoding and underpayments, which meant that these doctors actually deserved more money than they billed. Of course, these types of problems are still considered errors and "incorrect coding," so it would be best to put checks in place to prevent these issues going forward. In addition, the trend of undercoding suggests that the issues may have simply been errors. Consider the following examples of improperly-coded ED claims so you can avoid a place in CMS' next improper payment report.

Example 1: Suppose your ED physician records a visit with a comprehensive history, a detailed exam, and high-complexity medical decision-making (MDM). The coder submits a claim for 99285.

Is this coded properly? No. If the coder is accustomed to selecting E/M codes in the office or inpatient setting, he might have selected 99285 because he thought that only two out of three elements (history, exam, MDM) were required to select a particular code, but ED coders have to select a code based on all three components, says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow and vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

Solution: Therefore, since the documentation in the example featured a detailed exam and not a comprehensive one, this claim should have been coded with 99284 instead of 99285. This claim would have been marked as an upcode.

Example 2: A patient reports to the emergency department after hurting her leg while jogging. After a level-four E/M service, the physician decides that she has a closed tibial shaft fracture and treats it without manipulation. During the visit, the ED physician calls an orthopedic surgeon to discuss treatment options. The EHR says that the phone call lasted 12 minutes and the EHR calculator suggests a 99285.

Is this coded properly? No. Just because the physician spent 12 minutes on the phone doesn't mean you can bump the code up to the next level. ED codes do not include time as a descriptive component of E/M services, CPT^® states, "because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time."

Solution: Because the doctor documented a level four E/M visit, you should have reported 99284 and not 99285 in this instance. Auditors would have counted this as an upcode.

Resource: To read the full CERT document, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/AppendicesMedicareFee-for-Service2016ImproperPaymentsReport.pdf.