Preparing for 2011: Revenue boosters
[This column is written by Caral Edelberg, CPC, CCS-P, CHC, president of Edelberg Compliance Associates, Baton Rouge, LA.]
A new year is fast approaching, and with it comes unusual challenges for ED compliance. As recovery audit contractors (RAC) step up audit activities, many hospitals and ED practice groups are taking a second look at appropriate ways to ensure compliance without sacrificing revenue.
By now most providers understand the complex rules for documenting records to comply with 1995 Medicare Documentation Guidelines. However, a quick record review might indicate problems with isolated elements that compromise compliance and revenue. Ensure physicians understand how to document the following, particularly on moderate to high acuity cases:
- History. It should also include a review of the system with the statement "All other systems negative to my review" when it applies.
- Physical exam. Address all body areas and organ systems that are relevant with a brief statement on those with negative findings. Use an organized approach to documenting that identifies each body area/organ system so coders can differentiate.
- Medical decision-making. Provide a detailed description of the patient's symptoms, problems, and relevant history to support interventions and medical necessity. Medical necessity will be a major RAC focus for hospitals in 2011, and failure to provide necessary information for the ED visit may limit hospital revenue. In addition, be sure to:
Clearly document all orders-the facility won't bill for a service/intervention without a documented order.
Document your treatment plan for the ED course.
Document the rationale for interventions and any discharge instructions for follow-up. For example, "I believe the patient's condition requires hydration," or, "See internist in two to three days for follow-up testing, med reconciliation.
Provide differential diagnoses to support medical decision-making.
List diagnoses in order of importance. (No one group coders, physicians, or ED nurses should work in a vacuum. See the story, below.)
Although coding rules are vastly different for ED professional and facility coding, Aetna, one of America's largest health insurers covering an estimated 40 million enrollees, has announced plans to start basing its payment for the facility portion of ED services on the physician's E&M code. This payment strategy runs counter to CPT and Medicare directives. Numerous organizations, including the American College of Emergency Physicians and Emergency Department Practice Management Association, have raised concerns about the inappropriateness of this modification to established coding policy.
In its June 2010 Office Link Updates, Aetna announced, "Effective Nov. 15, 2010, payment for facility emergency department services will be based on the level of severity determined by the treating emergency physician. The emergency service evaluation and management code billed by the physician will be applied to the corresponding facility bill to determine the appropriate level of payment. Emergency department service evaluation and management codes are represented by the code range of 99281-99285. This policy will not apply to emergency room services which result in inpatient admissions." Until overturned, this means deficient documentation that results in down-coding of the physician level will impact the facility level as well for this payer, bringing additional focus on ED physician documentation.
In addition, Aetna has published a focus on reducing ED visits by taking a "multi-faceted approach to decreasing emergency room (ER) use by Aetna members when urgent care (UC) services would be an appropriate option instead. To address this issue, we are asking employers to educate their employees on urgencies, out-of-pocket expenses, and appropriate use of the ER vs. UC; in providing case management services to members who frequent the ER for non-ER services; in directing members to find the appropriate urgent care center in DocFind, our online provider directory, and through Informed Health Line, Aetna's 24-hour nurse line."
Aetna further directs employers to "help consider modifying your outgoing phone message to offer options, including `911,' urgent care, or speaking with the on-call doctor. We also hope that you will take some time to talk with your patients about the advantages of using UC centers and walk-in clinics for non-emergent care." Unfortunately, there is no information to help employers and their covered employees differentiate between a bona-fide emergency and a problem that is not. Shortly before this issue of EDM went to press, members of the Multi-State Managed Care Coalition met with Aetna. Aetna agreed to the following:
- The coalition will prepare questions regarding Aetna's new ED E&M Reimbursement Policy, to which Aetna will respond, so that a list of frequently asked questions may be developed for hospitals.
- The coalition will consider formulating an alternative approach to Aetna's new policy that would be responsive to the concerns Aetna has raised.
- Effective Nov. 15, 2010, Aetna will implement its new ED E&M Reimbursement Policy in monitor mode only, which will enable it to record all claims in which hospitals bill at a different level of severity from the treating physician without any change or reduction of reimbursement. After about 45 days, Aetna will evaluate the results and, if appropriate, re-visit the policy. The coalition expects to meet with Aetna then.
EMRs create new challenges By Caral Edelberg, CPC, CCS-P, CHC The emergence of electronic medical records (EMRs) has created numerous problems for coding and audit staff. In addition to learning new formats and reviewing longer records, entries can often be confusing and conflicting. Here are some problems from recent audits: See PMD in 24 hours (formatted discharge order). See specialist in 3-4 days (physician documentation). See PMD if problem worsens (nursing notes). The need for urgent follow-up v. follow-up only if problem worsens indicates a significant difference in the possible acuity of the patient, the level of problem being managed, and the risk to the patient who might not follow the ED's recommendation to be seen immediately. Orders for high level diagnostic studies (CT scans, MRIs, Doppler, etc.) that are added, removed, and added again without the physicians indicating the orders in their narratives. The need for these tests indicates a higher complexity of service only if they are performed. Until everyone in your ED is on board with the EMR, you'll want to cover as many bases as possible in the ED and nursing narratives. |
Who should chart audits? By Carol Edelberg, CPC, CCS-P, CHC Never have checks and balances been more critical to your practice and the hospital compliance program and revenue picture. Resubmitting records to dispute payment denials and audit findings has become today's norm. ED compliance relies on a complex system that demands checks and balances to ensure everyone understands the financial and legal repercussions of anything less than a well-managed system. Coders should not audit themselves. Physicians should not determine documentation guidelines themselves. Nurses should not develop facility assessment criteria (E&M levels) by themselves. All should be collaboratively involved in assessing and developing compliance and revenue processes and outcomes. What makes sense for clinical documentation might not tell the full story to support code choices. Interpreting documentation and applying it to coding policies might require physician or nursing input from time to time to clarify complicated clinical issues. Coding rules change constantly due to regional and national clarifications provided by Medicare, Medicaid, and private payers. Unfortunately, many gray areas still exist, and a collaborative effort between physicians, nurses, and coding staff might be essential to ensuring a best practices solution to today's growing revenue and compliance problems. |
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