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April 2, 2007

ED Coding’s Juggling Act
By Robbi Hess
For The Record
Vol. 19 No. 7 P. 10

In the frenetic, sometimes out-of-control environment of the emergency department, documentation tends to become less of a priority—making proper coding that much more difficult.

Because the emergency department (ED) is a difficult place for hospitals to maintain compliant billing and coding procedures, the balancing act between ED coding and billing can make someone feel as if they are walking a tightrope. The department must balance compliance obligations with patient care concerns and limited resources, not to mention the ED’s frantic pace.

The clock starts ticking the moment the patient comes through the ED doors and continues until the final bill for that visit has been processed and payment received. The seconds in between offer countless opportunities for hospitals to lose revenue. It is critical that EDs operate efficiently and process accurate charges, implement coding mechanisms, and have appropriate documentation.

Addressing the Issues
Brenda Cox, RHIA, CCS, director of coding operations at Health Information Partners, says one area lacking in the ED is proper and complete documentation.

“Oftentimes, with ER [emergency room] records, there is not enough documentation and it may not capture all of the services a patient receives,” she explains.

Issues arise concerning ICD-9-CM coding for visits. Coding systems serve an important function for physician reimbursement, hospital payments, quality review, benchmarking measurement, and the collection of general medical statistical data reporting. But, at times, not all ED diagnoses are captured, leading to lost revenue and faulty benchmarking data for provided services.

Nancy Hirschl, president of Hirschl & Associates, explains that omissions of secondary diagnosis codes may result in payment denials. “If there is no diagnosis to support the need for a test or procedure, denial is imminent. It’s important for physicians to document a patient’s past history, and it’s imperative that the ED coder assign the secondary diagnosis codes,” she says.

Patricia Ashley, LVN, CCS, vice president of hospital audit services for Health Information Partners, says coders don’t always query for more exact treatment information. “What is typically used when the records come back for coding is whatever documentation comes back with the chart,” she says. “I find that sometimes the secondary diagnosis or chronic conditions are not being documented or addressed. Patients are asked: ‘What symptoms are you presenting with, and what can we do to get you out?’”

Cox says better forms are needed to help address coding issues. “Providing better forms or templates would help to more accurately capture what was done in the ED. The forms should be generated by a team of ED personnel: doctors, nurses, and coders.”

Ashley says that while coding is an ongoing problem, some hospitals are getting better at addressing the issues. “Because of the pace of an ED and the fact that there are not typically the same physician staff in the ED, gathering or forming a committee of people to look at paperwork requirements is difficult,” she says. “The physicians feel they are there to treat patients, not complete paperwork. Both procedures, though, go hand in hand.”

Because staff may be on rotation—especially if the hospital is a teaching facility—continuity and follow-through are difficult. In some hospitals, the medical records department still oversees what is captured in the ED, and the nursing staff may oversee what is done medically. But the medical records department still needs to make certain everything is captured and procedures are coded correctly.

Medical Necessity for ED Visits
The ED should be the medical choice of last resort; it is not intended for routine medical care. Because of the relatively high charges for emergency care and problems with ED overcrowding, visits labeled inappropriate—those visits for nonurgent health problems—have come to light.

Determining what is inappropriate is not simple. When a patient comes to the ED, hospital staff collect information about the patient’s symptoms and medical history, but ED coding typically captures only the diagnosis, which is determined from an examination.

For example, a patient complains of chest pain and nausea (urgent)—early warning signs of a heart attack—but is later diagnosed as having muscle-related chest pain (nonurgent). This visit could have been deemed inappropriate, even though the initial reasons for going to the ED weren’t apparent and pointed to a heart attack.

Nursing and physician documentation must support the level of service rendered as well as all procedures for payment. Medical necessity begins with the chief complaint and extends throughout the visit. All codes must be supported in all documentation to establish the need for the ED visit.

“Another issue is if procedures are performed in the ED but the codes don’t correspond, denials are the result,” Cox says. “There are five different ED levels that patients can be assigned to if certain tests are given, a diagnosis needs to be captured or a reason must be given that could correspond to those tests. But if the tests were given [with] no medical reason attached, the fees resulting from those tests could be denied. Also, if other chronic or coexisting conditions that a patient presents with which are monitored during the stay need to be accounted for in the coding.”

Steps to Ensure Accurate Coding
In Ashley’s opinion, medical records should oversee ED coding.

“You need to make sure coders are qualified and are offered continuing education and that their books are updated on an annual basis,” Cox says. “Providing both internal and external audits of the coding department ensures coding accuracy.”

Susan R. Glass, RHIT, CCS-P, of A-Life Medical, explains that the proper use of modifier -25 continues to be an issue for coders. “There continues to be numerous articles and training documentation about its use,” she says.

According to Glass, the description and intended usage of modifier -25 as provided by the American Medical Association CPT book is: “Significant, Separately Identifiable Evaluation and Management [E/M] Service by the Same Physician on the Same Day of the Procedure or Other Service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier -25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery.”

The Office of Inspector General (OIG) published a study in November 2005 that detailed significant incorrect use of modifier -25. The OIG found that 35% of claims using modifier -25 allowed by Medicare in 2002 did not meet program requirements. The result was $538 million in improper payments. Problems ranged from definite inappropriate usage to insufficient documentation to determine if the use was appropriate, and needless use (an E/M with a modifier -25 in the absence of another procedure).

Modifiers -25 and -59, appended to the visit level, are commonly used in billing of ED services but must be applied appropriately to avoid improper billing or payment denials for ED services.

In many hospitals, Hirschl explains, the growing trend is to have HIM be responsible for at least validating the charges assigned by the ED staff. “HIM needs to know the rules and responsibilities set forth by Medicare,” she says. “The role of HIM in the ED is huge and has a large impact on the facility’s bottom line.”

Admit to Observation/Inpatient Issues
“Documentation is not as clear as to whether patients are admitted to observation level of care or as an observation,” Ashley explains. “Lately, I see so much more with doctors not making the call on whether they should be an inpatient or an observation case. But that is more of a billing than a coding issue.”

New APC Rules for 2007
ED managers must manage responsibilities relating to ED billing and coding issues, and they are expected to participate in ensuring the ED’s financial success. Additionally, the implementation of the Medicare Outpatient Prospective Payment System and its payment structure of Ambulatory Patient Classifications (APCs) dramatically changed the way ED services are billed to Medicare. Because of this, it is critical that the ED’s needs and responsibilities be integrated into the efforts of other hospital departments.

Prior to APC implementation, ED reimbursement was based on a cost-to-charge ratio. Under APCs, a payment is determined by the actual work performed during a patient’s visit as it translates into codes for the Health Care Financing Administration Common Procedure Coding System. These codes eventually translate into an APC, and the hospital receives payment associated with the APC groups.

Changes in the APC rules for 2007, Hirschl says, primarily deal with E/M criteria. She says there also needs to be documentation to support at least 30 minutes of critical care services.

“Developing and maintaining valid, viable ED E/M criteria is essential to making sure a facility is paid appropriately and that it is in compliance,” she explains. “In my opinion, it’s imperative for HIM professionals to step up and get involved with every aspect of ED coding. At the very least, they need to be validating and making certain codes are assigned properly.”

Procedure CPT Billing Issues
Tom Darr, MD, chief medical officer for Ingenix and a practicing ED physician, agrees that facility billing in general has less granularity and visibility.

“The general concept around the detail is that CMS [the Centers for Medicare & Medicaid Services] is trying to introduce a granularity around cost issues so it can more accurately produce and manage costs of the ED,” he explains. “There is a large sector of people in our society who have no insurance coverage, and they seek help in the ED for their care. It’s a very expensive place for people to go for routine care.”

The insidious portion, Darr says, is that if a patient cold calls a provider and wants to be seen, that doctor’s office can decide whether to see them based on insurance coverage, whereas if they come into the ED, they will be seen no matter what.

Commonly Miscoded Areas
One of the most commonly miscoded areas in the ED, Hirschl says, is infusion and injections. “Infusions and injections relate to nursing documentation, and that is something that needs to be addressed and monitored to make certain proper levels of reimbursement are being received as it relates to the number and frequency of injections,” she says.

E/M Leveling Strategies
Ashley says that each facility needs to create its own point sheet and E/M leveling strategies. “Hospitals should look at their strategies annually because every year the codes change so the rules can change as well,” she says. “What the HIM department can do is audit [ED] records that coders have done and see if leveling codes are correct.”

In larger hospitals, Ashley says, someone from the medical records department is dedicated for the ED, so they can monitor everything immediately instead of having it flow to medical records, then filter back down for clarification.

“The role of HIM as we know it has to change,” Hirschl says. “HIM ED coding professionals need to become charge and data analysts and validate, if not assign, the charges that come out of the ED. They also need to be more involved in nursing documentation and work with the nursing departments to improve and enhance documentation practices.”

Bottom Line
Ongoing education and internal audits are crucial to ensuring everyone codes the same and that all necessary information is captured, Ashley says.

Cox agrees: “Coder education is the single most important area that needs to be addressed. You can’t have enough of it and not only should audits be performed, the coders should receive feedback on those audits.”

Problems with billing begin in the ED and will continue throughout the billing process unless a system of checks and balances is implemented, maintained, and monitored. The average ED stands to lose between $5 million and $8 million in charges.

Review Pointers
According to information from A-Life Medical, it is advisable to have periodic, focused review of how your practice assigns modifier -25. The following dictation suggestions are offered to assist coders in determining a valid, significant, and separately identifiable E/M service. These dictation practices, when adopted by the physician, can help ensure the appropriateness in billing an E/M service code with a procedure or other service CPT code.

1. Verify adequate documentation of the three key components of the E/M service (history, exam, and medical decision making). Documenting only the evaluation of a separate problem without documenting the management component (what was done about the problem) is incomplete.

2. Although there may be only one definitive diagnosis code to be assigned, the provider should document all signs, symptoms, and confirmed diagnoses as well as all differential diagnoses. The physician should state the reasoning behind ordering of tests.

3. The diagnoses, signs, and/or symptoms may prompt the need for both an E/M and procedure, and the same ICD code can be reported for each, but documentation should indicate the separate medical need to perform each separate service.

4. Always document the surgical, presurgical, and/or postsurgical services rendered separately. One way the provider may make such separate notations easily identifiable is to confine all documentation related to a procedure to one area of the dictated record (ie, a separate paragraph).

5. An E/M service with the modifier -25 should be reflected in the documentation as a separate, identifiable problem or issue requiring an E/M service. The documentation should reflect the level of E/M service (ie, 99211-99215), and should reflect at least two of the three key components of an established E/M office service. Specifically, the E/M service should include the evaluation of the significant, separately identifiable finding and management (two of the three key components of an E/M service). Just identifying the finding without decision making does not meet the E/M criteria.

6. Treatment plans should be clearly identified when they are unrelated to the procedure. If a physician prescribes medication for wound care (head laceration repair) and different medications for dizziness (head trauma), make sure the documentation clearly identifies the different medical need(s).

7. Examinations of body areas and/or organ systems surrounding or near an area where an injury such as a fracture or possible fracture was splinted, casted, or strapped should indicate any differential diagnoses being considered to make it easy for anyone reading the documentation to identify whether separate exams took place in the same visit. When the separate exam involves an area close to the injury, it can be difficult to identify the separate medical need. While the E/M does not require a separate diagnosis code from that assigned to the procedure, the E/M must be medically necessary for reasons beyond what was necessary to perform the procedure.

8. Modifier -25 can only be used to bill a significant, separately identifiable E/M service which occurs on the same day as a primary procedure or service that has a global coverage period or is otherwise identified as bundled (under National Correct Coding Initiative edits) when performed by the same provider. If the significant, separately identifiable E/M service occurs during a postprocedure global coverage period but not on the same day of the procedure, use modifier -24. The physician may claim both the E/M service and the procedure by appending a modifier -25 to the E/M service code. (Modifier -25 should be used with E/M codes only and not with surgery/global or other service codes.)

9. Under global surgical exceptions, the patient’s medical record documentation is expected to clearly contain evidence that the E/M service performed and billed was “above and beyond” the usual preoperative and postoperative care associated with the procedure performed on that same day. This is because the “usual care” for the typical patient is already covered by the procedure code. The need to perform an independent E/M service may be prompted by a complaint, symptom, condition, problem, or circumstance which may or may not be related to the procedure or other service provided. The record should document an important, notable, distinct correlation with signs and symptoms to make a diagnostic classification or demonstrate the distinct problem.

— Robbi Hess, a journalist for more than 20 years, is a writer/editor for a weekly newspaper and a monthly business magazine in western New York.