How to Catch the Most Commonly Missed Charges in the ED
Published on Wed Sep 01, 1999
Few healthcare providers are in more of a reimbursement crunch than emergency physicians: Medicare and many commercial third-party payers are cutting reimbursement levels, managed-care plans often strenuously attempt to limit their insured members ED visits, and, as always, the hospital emergency room must absorb the cost of a large portion of unpaid care for indigent patients.
In this climate, ED physician groups can hardly afford to leave any earned revenue uncollected, but emergency medicine management consultants and billing experts often tell us that emergency physicians frequently leave valid charges on the table due to errors in coding and documentation.
What are the most commonly missed reimbursement opportunities in the emergency department? To find out, ECA interviewed two coding and billing consultants who regularly perform internal coding audits for emergency physician staffing groups: Randy Thompson, CPC, coding consultant with Healthcare Consultants of America, Inc., in Augusta, GA, and Susan Callaway-Stradley, CPC, a former hospital and emergency department coder who is now an independent coding consultant and educator based in Charleston, SC, and was recently named as AAPCs coder of the year.
The five areas to watch out for according to Thompson and Callaway-Stradley are:
1. Under-reporting the evaluation and management (E/M) level for ED visits. Both Callaway-Stradley and Thompson report that many ED physicians are unfamiliar with the methodology for coding E/M services (99281-99285). As a result, they often report the level of service based on a vague impression of how difficult the physician felt the treatment decision was to make. For example, Callaway-Stradley relates, many physicians feel that any visit to the ED that involves the treatment of a cold should warrant no more than a Level 2 (99282) ED service code.
They may see someone with an upper respiratory infection who presents with a fever and some potentially severe side effects and still feel that it is a Level 2 service, because the diagnosis was readily apparent to them and did not take a long time to make, she continues. A seasoned physician may not take a long time making this diagnosis, but a young doctor might.
Frequently, the problem is not a lack of documentation, but the failure of the physician or person who assigns the visit code to fully credit all of the available information.
Many times, they document the visit correctly, Thompson says. They just dont select the appropriate code for that service. When I go back and review records and look at the presenting problems and similar items, I often find a lot of money left on the table, she adds.
2. Not including sufficient documentation of wound repairs. Physicians may document a visit adequately, but they often omit needed information when reporting procedures, [...]
