Work closely with coders, or ED revenue may be lost
Good documentation often coded incorrectly
By Caral Edelberg, CPC, CCS-P
President/CEO
Medical Management Resources/Team Health
Jacksonville, FL
Without connectivity between emergency department (ED) clinical staff, business office, medical records, and compliance, your ED stands to lose significant revenue.
Streamlining your ED coding and billing system isn’t something you can do alone. It takes the expertise and cooperation of numerous individuals working together on each element of the process. However, the rewards are great, both in the areas of improving revenue and in assuring conformance with the hospital compliance program.
The amount of revenue you may be losing depends on many components of your ED coding and billing process. It is not uncommon to find between $15 to $30 per patient in lost ED facility charges on just levels and procedures alone.
The lost net revenue for Medicare patients is quite easy to assess by identifying improperly coded facility levels or procedures that were omitted altogether and then assigning the ambulatory payment classification (APC) payment amount to each.
Here are ways to collaborate with coders to improve reimbursement:
• Ensure criteria are followed.
Nursing criteria must accurately and uniformly reflect the services provided to patients by ED staff. Compliance problems will occur without use of objective criteria by the coding team.
It is not uncommon to find excellent documentation by clinical staff that is not accurately interpreted and coded. Coders and clinical providers must work together to develop an understanding of the underlying factors illustrated by the words entered in the medical record.
Providers should earmark select cases that illustrate moderate to high levels of acuity, resources, and patient care. Track these cases through the coding and billing process or work with coders prior to assignment of the codes to discuss how coding will be performed based on submitted documentation. Discuss the differences in how coders interpret the documentation and apply coding rules.
The Center for Medicare & Medicaid Services initially proposed new facility levels codes starting in January 2003, but it didn’t implement them in the final rule. It looks as if it will be 2004 before a nationally uniform facility coding criteria will go into effect.
Until then, you must ensure that levels are stratified by acuity and resources, and you must ensure that coding staff follow the criteria. If criteria are too subjective, coders will not be able to assign levels to services uniformly, which is a problem for revenue and compliance.
• Perform outside audits.
Routine outside audits can help you stay on track and identify areas that need improving. If all seems to be working well but there are no outside audits to ensure that internal criteria are followed and coding and billing are being performed under current rules, there may be a compliance problem that ultimately will result in paying some of that revenue back.
• Work with coders to review denials and suspended claims.
When documentation, coding, and billing are performed appropriately but there is no ongoing review of denials and suspended claims, coders never learn what rules certain payers may follow. In other words, the work is done, but the payer wants it reported in a special language.
• Ensure that coders identify additional procedures.
Coding for surgical procedures performed in the ED is a new concept for facility billing introduced with APCs. Coding of these services depends on documentation provided by clinical staff, and it can be missed easily if documentation is not complete and detailed.
When coded correctly, these procedures add significant revenue to the ED.
Review chargemaster regularly
• Work with coders to monitor the ED chargemaster.
If documentation and coding are correct but the chargemaster is not functioning appropriately, causing services that are coded to be omitted from the billing form, then revenue is lost.
The ED chargemaster requires ongoing revision to reflect all services that can be performed in the ED — approximately 450 codes. You must review it on a regular basis, communicate with coding staff to identify services that are performed but not included in the chargemaster, and be sure these chargemaster codes appear on the billing forms when used.
• Work with coders to ensure adequate documentation of medical necessity and the service rendered.
You cannot overestimate the importance of documenting medical necessity for the treatment that is provided to ED patients. Under Local Medical Review Policy (LMRP), Medicare determines the conditions and diagnoses that must be identified on the claim for services to be paid.
Often, the services are performed, but documentation does not provide enough detail to allow coders to identify the services to the highest level of specificity required by Medicare.
Clinical staff in the ED won’t know that is expected of them in documenting these services unless someone in coding and billing provides the necessary feedback on denied or suspended claims.
To enhance collaboration between coders and ED staff, plan routine meetings to discuss ways to address documentation issues that affect coding. Some ED services that require LMRP monitoring include electrocardiograms, pulse oximetry, troponin, cardiopulmonary resuscitation, and chest X-rays. Without this level of oversight, you can expect billing errors and lost revenue.
Without connectivity between emergency department (ED) clinical staff, business office, medical records, and compliance, your ED stands to lose significant revenue.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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