ED Coding and Reimbursement Alert

Payers will give high-level E/Ms a closer look, experts say There is some potentially bad news for ED coders: Based on evidence from a just-released poll, claims reporting level-four and level-five evaluation and management services could be examined even further under the payer's microscope.

Why? A recent survey by American Hospital Directory showed that E/M levels in the ED increased in the past few years.

For example, 24 percent of ED E/M visits were level four (99284, Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity) in 2004.

In 2002, only 20 percent of these services were level four. Experts offer these tips for dealing with an E/M audit in your ED: Check if You-re an -Outlier- When a payer is deciding which EDs to audit, it will go after billing outliers first. When looking for outliers, insurers check E/M coding patterns. If an ED's coding falls outside the payer's normal coding patterns, it is a potential audit target.
 
But even an outlier audit is not a signal to start panicking. Outlier status does not necessarily equal outlaw status with payers, said Stephanie Jones, NR-CMA, NR-CAHA, CPC, vice president of operations at Aztec Medical Systems in Miami during a recent Coding Institute teleconference.

-If your office is an outlier, it does not necessarily mean that you are billing improperly. But if you are an outlier, you must make sure your coding is accurate,- Jones said.

Consider this anecdote from Dennis Mihale, MD, chief executive officer of Parses, a claims auditing company in south Florida: Auditors identified a surgeon as an outlier because -his billing seemed to indicate that every patient he treated was in a train wreck.-

However, it turned out that he was a trauma surgeon, Mihale says. So, in this case, the surgeon's billing was entirely correct and legal.

If a medical practice treats lots of high-risk patients, as EDs sometimes do, it will probably use more high-level E/M codes. Just make sure that your E/Ms are all coded at the proper level, especially if you-re filing lots of level-four and -five E/M services.

In the ED setting, predictors of right-shifted E/M distributions (i.e., more patients needing level-four or -five service) correlate with patient acuity -- in other words, EDs with high admission rates, urban settings, trauma designations, or referral centers will tend to have higher E/M levels on average, says Michael A. Granovsky, MD, CPC FACEP, vice president of MRSI, an ED coding and billing company in Stoneham, Mass. Make Sure Auditor Understands ED Coding There are a few important differences between E/M services in the ED and elsewhere, and whoever is [...]