Here's how you can ramp up your department's revenues
[This quarterly column on coding in the ED is written by Caral Edelberg, president of Edelberg Compliance Associates. If there are coding issues you would like to see addressed in this column, contact: Caral Edelberg, CPC, CCS-P, CHC, Edelberg Compliance Associates, Baton Rouge, LA. Phone: (225) 454-0154. EFAX Number: (225) 612-6904. E-mail: [email protected]]
National economic paranoia seems to have taken over, and although ED volumes continue to climb, joblessness combined with the economic downturn promise to make it a rocky 2009 for many. There is a lot of emphasis on patient satisfaction, safety, and security these days, and each requires resources to manage. To sustain our objectives, it will be necessary to ensure the revenue streams to support them.
The realm of ED documentation, coding, and billing continues to change as we see payers clamping down on perceived overpayment through audits and recoveries. Here are a few things you can do that might give you added revenue opportunities without risking compliance liability:
• Revisit your ED nursing levels and the content of each.
The higher acuity levels (99284 and 99285) reflect the highest and best resources you provide. If they aren't documented and used appropriately by nursing, coding, and billing staff you are allowing too much revenue to slip away. Have nurses and coding staff take another look at the services that each level supports and move things around if necessary. That intubation probably belongs with the critical care and not the intermediate ED visit level.
• Modifications to billing rules for observation make it imperative that you ensure your 99284 and 99285 ED services are defined appropriately.
Observation is a billable and valuable service. However, as a composite service requiring billing of an ED visit (99284, 99285) or 99291 (critical care) in addition to observation during or following the ED visit, Medicare will drop the payment for observation and pay only the ED level if the code combination isn't right. You are vulnerable to a significant financial loss to your institution, and this might reflect a lack of knowledge of similar issues in other departments as well. (Where there's smoke, there's Medicare!)
Improperly defined nursing criteria can affect your observation revenue if you are unable to bill the 99284, 99285, or 99291 critical care required in addition to the observation service. The new observation payment rules require that ED 99284, 99285, or 99291 critical care be billed in addition to the observation service. A payment of $315.51 (99285) or $212.59 (99284) will be made for the ED visit as required for payment for observation (Extended facility assessment and management composite level II). Observation then is paid at an additional $638.66. So, if you bill it right, the ED and observation stay will provide you a minimum payment of $954.17 (99285 with Extended assessment/observation) or $851.25 (99284 with Extended assessment/observation). Multiply this amount times the number of times your ED provides treatment at this level, and you have a significant financial "reward" for your efforts. Remember, content of the code levels determines how they are billed, so don't underreport your higher acuity levels as a result of overly restrictive nursing criteria or criteria that are being used incorrectly.
Medicare is aware that the dramatic change in the observation billing concept might encourage hospitals to rethink how they are billing the associated evaluation/ management (E/M) levels. In the 2009 final rule, Medicare expressed, "We do not expect to see an increase in the proportion of visit claims for high-level visits as a result of the new extended assessment and management composite APCs 8002 and 8003 adopted for CY 2008 and finalized for CY 2009. Similarly, we expect that hospitals will not purposely change their visit guidelines or otherwise upcode clinic and emergency department visits reported with observation care solely for the purpose of composite APC payment. As stated in the CY 2008 OPPS/ASC[outpatient prospective payment system/ambulatory surgery center] final rule with comment period (72 FR 66648), we expect to carefully monitor any changes in billing practices on a service-specific and hospital-specific level to determine whether there is reason to request that Quality Improvement Organizations (QIOs) review the quality of care furnished, or to request that Benefit Integrity contractors or other contractors review the claims against the medical record."
Those statements don't prevent adjusting your ED criteria, but beware of a sudden jump in higher-acuity ED visit codes (99284-85 and 99291 critical care) without rationale. Your documentation must support the level of service. This is the easiest place for a QIO to look and find fault with your coding. For example, if your physicians and/or nurses are forgetting to identify the amount of time spent performing critical care services and you can't support 30 minutes or more but bill it anyway, you might find payment overturned on audit. EDs provide a much higher volume of critical care than is usually billed because of documentation problems so:
— be sure it's documented when performed;
— be sure it's billed when documented correctly;
— be sure all agree as to the content of critical care and how it should be documented before payers come calling.
• If documentation templates still are in use in your ED and they've been modified and remodified over time, create a task force to take another look at your process and content.
This task force will help ensure that all of the elements necessary for coding are there and being used correctly by your coding staff. Physician documentation supports professional and technical billing, and the better documented your clinical services appear, the less likely payers are to recoup payments on audit. Good documentation supports accurate coding.
Too often, documentation templates are used inconsistently by providers, interpreted inaccurately by coders, or fail to "prompt" history and physical exam elements consistent with the chief complaint. It takes clinical and coding staff working together to develop templates that provide the prompts for clinical and coding content. Examples are body areas vs. organ systems, components of the history of present illness vs. review of systems or default codes, and documentation when the provider is unable to obtain (UTO) required elements of documentation. The less subjective your documentation content, the better the opportunity for coders to accurately pick up the required elements or coding, thus increasing the likelihood that auditors will agree with your code choices.
National economic paranoia seems to have taken over, and although ED volumes continue to climb, joblessness combined with the economic downturn promise to make it a rocky 2009 for many. There is a lot of emphasis on patient satisfaction, safety, and security these days, and each requires resources to manage. To sustain our objectives, it will be necessary to ensure the revenue streams to support them.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content