Advancements in procedures and new technology in the Emergency Department (ED) have altered the intensity of resources necessary for appropriate patient care. Additionally, with Urgent Care Centers flourishing, higher acuity patients are presenting to the ED. These shifts in patient care require constant surveillance of the facility ED Evaluation and Management (E/M) tool to ensure the hospital is effectively capturing the resources expanded to care for patients. Is your facility E/M tool keeping up?
WHY IS THE facility ed e/m tool important & Payer Denials
The primary objective of the facility ED E/M tool is to capture the intensity of the patient visits, which in turn ensures appropriate revenue capture for ED services. However, hospitals also increasingly faced with greater payer scrutiny for high-level ED facility E/M billing, often leading to denials or automatic downcoding.
Therefore, ensuring that your tool is an accurate representation of the ED services rendered, and is utilized consistently, provides the platform under which your facility can fight appeals and mitigate reduced reimbursement.
background
According to The Center for Medicare and Medicaid Services (CMS) the criteria used to assign the technical E/M level should represent the volume and intensity of resources utilized by a facility to provide care to a patient:
“We will hold each facility accountable for following its own system for assigning the different levels of HCPCS codes. As long as the services furnished are documented and medically necessary and the facility is following its own system, which reasonably relates the intensity of hospital resources to the different levels of HCPCS codes, we will assume that it is in compliance with these reporting requirements as they relate to the clinic/ emergency department visit code reported on the bill. Therefore, we would not expect to see a high degree of correlation between the code reported by the physician and that reported by the facility.”[1]
CMS’ 2008 Outpatient Prospective Payment System (OPPS) Final Rule did not implement national guidelines for clinic or ED visits. Rather, it outlined eleven (11) standards that should be included in a facility’s E/M guidelines as follows:
Follow the intent of the CPT code descriptor – the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
Be based on hospital facility’s resources, not physician resources.
Be clear to facilitate accurate payments and be usable for compliance purposes and audits.
Meet HIPAA requirements.
Require only documentation that is clinically necessary for patient care.
Not facilitate upcoding or gaming.
Be written for records, well documented, and provide the basis for selection of a specific code.
Be applied consistently across patients in the clinic or emergency department to which they apply.
Not change with great frequency.
Be readily available for intermediary (now Medicare Administrative Contractor) review.
Result in coding decision that could be verified by other staff, as well as outside resources.
action plan
To effectively analyze your facility ED E/M tool, we recommend a multidisciplinary team approach. Below is a proposed work plan to ensure compliant and defensible billing of ED E/M services with appropriate reimbursement.
Step 1 - Prospective Audits
The first step in the process is conducting prospective audits to validate if nursing documentation supports the assigned level. The purpose is not only to isolate opportunities, but also to ensure your facility is better positioned to defend your billing in the event of an audit, denial, or appeal.
Technical resource intensity can be impacted as ED interventions evolve over time or new interventions are implemented. As such, utilizing a nationally recognized tool to compare against your tool enables your hospital to isolate deficiencies.
Most importantly, the facility ED E/M tool should not be static! Continually monitoring the tool is essential to highlight areas for needed documentation workflow updates, electronic health record (EHR) enhancements as well as updates to internal guidelines and definitions to reflect new interventions.
Step 2 - Clinical and Coding Staff Education
A significant component to a holistic approach for reviewing your facility ED E/M level assignment is evaluating staff knowledge and education needs with a goal of ensuring ED clinical staff are provided with a fundamental overview of facility ED E/M level assignment, and facilitating an understanding of the integral role their clinical documentation plays in deriving the appropriate visit level. Further, ensuring coding staff have a comprehensive understanding of appropriate application of the facility tool being utilized, definitions for each itemized resource on the tool and where to find all applicable documentation will enable consistent level selection that can be verified by other staff or outside resources.
After the prospective claim review, facilities are positioned to facilitate education with the clinical and coding staff to ensure optimal efficiency and appropriate reimbursement.
Step 3 - Payer Policy Analysis
Finally, being cognizant of payer-specific facility coding guidelines for level assignment as compared to your documentation patterns and internal tool can highlight opportunities for documentation workflow refinement and targeted education to ensure appropriate support for resource intensity.
If the facility’s tool is being consistently applied and you are still receiving denials, often, those payer denials are driven off an internal algorithm based on diagnosis coding. Establishing formal denial trending by payer and working with Contracting to appeal or arbitrate claims based on the terms outlined within the payer contract is essential to affect change. Importantly, do not let a payer dictate your facility ED E/M level!
Still have questions or need help evaluating your facility ED E/M billing processes?
SunStone offers services specifically geared toward analysis of accurate facility ED E/M level assignment, facility leveling tool analysis, peer comparison, and prospective claim reviews, ensuring compliance while achieving maximum revenue capture. If you have any questions, please contact Vonda Moon, Senior Principal at vondamoon@sunstoneconsulting.com or Joli Fitzgibbons, Senior Director at jolifitzgibbons@sunstoneconsulting.com or Danielle Wyld, Senior Manager at daniellewyld@sunstoneconsulting.com.
References:
[1] 65 FR No. 68, April 7, 2000