Part 1: Emergency Department Charge Capture: Keys To Success

The emergency department for any hospital is an arena of significant human drama, consequence, and acuity on any given day. It’s also hugely important for the financial well-being of the hospital, as it is key to unplanned and episodic revenue. The demands on personnel for both providing care and documenting it are acute and time-sensitive.

The unique demands emergency medical care puts on providers places a premium on the value of planning and processes for charge capture. Based on a webinar by Bill Malm, an ED practitioner and experienced member of our charge capture team, we have created three resources to help guide your emergency department revenue cycle:

• Emergency Department Charge Capture: Keys to Success
• Fighting Emergency Department Charge Leakage
• Trauma Activation and the Emergency Department Revenue Cycle

As you can see, there’s a lot to cover, so we’ll skip the waiting room and jump right into the material.

The Emergency Medical Treatment and Labor Act (EMTALA)

One of the major differences between emergency departments and planned services is managing the requirements for EMTALA — the Emergency Medical Treatment and Labor Act. Enacted by the U.S. Congress in 1986, it requires facilities to provide emergency care to all patients, regardless of insurance status or ability to pay. EMTALA also requires any hospital receiving Medicare payments to:

• Provide incoming patients with a medical screening examination (MSE)
• Stabilize patients who have an emergency medical condition
• Transfer patients or accept them as appropriate to the care their facility can provide

In practice, this means that medical screening may not be delayed to inquire about the patient’s financial status or insurance coverage. Because of this, registration generally occurs in two phases:

A short registration is where just enough information is collected to ensure a medical record can be created and physician orders are able to be performed. Generally, this includes name, date of birth, social security number, and address, to ensure that the patient care is attributed to the correct Medical Record Number (MRN) or if a new MRN needs to be created to start the care. This short registration is generally performed during the triage by nursing.

The complete registration includes validation of short registration data and determines insurance coverage, eligibility, guarantor, and subscriber information. Generally, this more detailed interview is performed bedside as soon as the Medical Screening Exam (MSE) is deemed complete by the physician.

Clinical Care and Documentation

It’s no surprise to anyone who has spent any time reviewing emergency department revenue cycle that documentation is the cornerstone for a healthy charge capture process and provision of quality care. There are four key categories of charges that help us break down the discussion:

• Evaluation and Management Services
• Surgical / Medical Procedures
• Supplies
• Medications

We’ll take a look at each area and offer some insight from a charge capture perspective.

Evaluation and Management Services

As we began our exploration of this topic, we asked our participants to tell us how their facility manages determination of the E/M Level (selection of AMA CPT Codes 99281-99285, familiarly known as levels 1 through 5). The graph below depicts the responses we received:

As you can see, there’s nearly an even split between facilities arriving at E/M level through a software-based automatic point generation system, and those who derive manually through chart-review by coding or charge entry personnel. Some hospitals have nursing personnel do this review, and still others use specialized IT or Data teams.

Automated E/M calculation is increasingly common, so for nursing staffs, there is usually a combination of scripted questions (for example when documenting a laceration) and, information that needs to be noted and recorded proactively, for example: feeding or moving a patient, one-to-one care necessity, or dealing with a combative patient. The Medication Administration Record (MAR) generally drives the charges for pharmacy items. We’ll discuss medications in more detail in a moment.

Determining E/M Level

While physicians will use guidelines from either AMA CPT Guidance or CMS guidelines, facilities almost invariably use CMS guidance. That guidance is provided in the 2008 OPPS final rule. It’s worth noting that many commercial payers have their own facility E/M criteria. One such payer is Humana, whom does not follow the CMS instructions, but use similar concepts.

Eleven Guidelines of Clarification by CMS

Below are the E/M coding guidelines from CMS based on the 2008 OPPS Final Rule. Refer to page 66,805 at the link.

1. The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
2. The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources.
3. The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits.
4. The coding guidelines should meet the HIPAA requirements.
5. The coding guidelines should only require documentation that is clinically necessary for patient care.
6. The coding guidelines should not facilitate up-coding or gaming.
7. The coding guidelines should be written or recorded, well-documented, and provide the basis for selection of a specific code.
8. The coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply.
9. The coding guidelines should not change with great frequency.
10. The coding guidelines should be readily available for fiscal intermediary (or, if applicable, MAC) review.
11. The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.

We shy away from emphasizing any of the specific 11 guidelines, but if we had to pick where to spend extra time, we’d focus on #7, 10, and 11. Coding guidelines should absolutely be well-documented and functional, and part of your auditing process should be to assure this is the case. A good way to test this is to give similar records to different personnel and analyze the results.

For software-generated E/M, it’s a good idea to review the following questions and make plans to address any gaps you identify:

• Does your team have control or final selection over the calculations, or can only the vendor change the point system?
• Can your facility adapt criteria to meet changing needs? (e.g. for COVID-19 processing)
• Is the system consistently recommending levels 4 and 5, creating potential for outside audit?
• Are you routinely performing internal audits of the calculations against your documentation?

Keep a close watch on these calculations anytime you undertake a change that feeds information into these systems, such as upgrades and system patches. We’ve seen facilities default to both high and low E/M levels due to systematic errors. Oversight is always critical, but especially so when technical changes are planned.

Surgical and Medical Procedures

Surgical and medical procedures are where charge capture specialists consistently find the most missed reimbursement opportunities. These misses usually stem from inconsistencies, or unavailability, of good templates and processes.

The constant push for leaner teams makes it exceedingly difficult for nurses to keep pace with documenting physician-performed procedures. Frequently missed information includes lengths, locations, and depth of lacerations. We also often see incomplete templates within the EMR that leave too much room for interpretation, resulting in erroneous or incomplete documentation. Without specific procedure forms that will ensure capturing required detail, coding professionals can often miss documentation – even (or especially) when clinicians create a large volume of notes. Missing information on medical and surgical procedures leads to reimbursement shortfalls that are often higher than the visit level reimbursement.

Common Emergency Department Surgical Procedures

Many facilities and solutions have good documentation templates for:

• Intubation – Emergency
• Incision and Drainage
• Laceration Repair(s)
• Live Birth
• Line Insertion
• Pleural Tap / Chest Tube
• Fracture Care

Some other very common emergency department surgical procedures to consider for documentation templates include:

• Foreign Body Removal
• Anterior / Posterior Nasal Packing
• Gastric Evacuation / Blakemore
• Casting and Splinting — note that these tie to prosthetics and orthotics, so specifics are key for appropriate supply charges
• Incision and Drainage
• Foley
• Lumbar Punctures
• Fracture Manipulation / Reduction

Common Medical Procedure Guidance

Below are a few guidelines and charge characteristics for a list of common medical procedures in the emergency department setting.

Infusions and Injections

It’s critical to document the site, start, and stop time for infusions. Many hospitals have moved to pumps that record all this data automatically. This also assists with capturing shift changes and supply usage; where, for example, a new bag can’t be started without the pump being reset.

EKG: 12-Lead & 3-Lead Rhythm Strip

You’ll want to record that these procedures are done distinctly. Overcharges occur, too often, when charging a 3 lead EKG and it is really just the cardiac monitoring, which is considered the standard of care.

Respiratory Treatments / Aerosols

These have to be provided by Respiratory Therapy with a physician order to be charged separately, otherwise it’s part of the nursing standard of care. However, nursing aerosol administrations can be added to your point system reflecting the facility resources

Pulse Oximetry

This is considered the standard of care when resulting from cardiac monitor. However, it can be charged when ordered by a physician and specific in nature, such as overnight monitoring or sequential readings.

Cardioversion

Cardioversion is not typically done in the emergency department unless the patient has an unusually irregular or rapid rate. Remember, it’s never used on ventricular rates, only atrial. Also note that cardioversion has a CPT code, whereas defibrillation does not. Defibrillation is generally emergent and not planned in advance such as cardioversion. Defibrillation charges are generally included in the point system for Cardiac Arrest events.

Other relatively common medical procedures in the emergency department to review include CPR, temporary transcutaneous pacing; echocardiography; and moderate sedation.

Supplies

While supply generally doesn’t represent a significant source of reimbursement, it is a significant source of a facility’s resources in terms of costs. So, accurate supply management does have significance in terms of cost reporting, and for future rate setting and negotiations.

A chronic source of problems with supply is an inaccurate CDM and/or labelling process that allows too much leeway for entry personnel to make mistakes.

This is why bar code systems have become preferred. They can be scanned easily and it ensures accuracy in the system. We find in charge capture, the majority of issues come from supplies being charged that don’t match the procedure recorded. Note also that “preference card” charging can become inaccurate if the supply link is incorrect, resulting in the wrong supply charge.

Supplies in the ED are both costly and voluminous, and frequently they’re managed within the procurement domain. The good news is that issues can be found rapidly with inventory control. What you have listed as stocked should be equal to what has been charged plus the material remaining on shelf. If this equation doesn’t consistently reconcile as it should, a root cause should be determined. Determine if the supplied item is linked incorrectly, or if there is a failure to charge it in the first place.

Medications

Proactive pharmacy analysis is important. Pharmacy will typically review the medical order and ensure that the correct dosage is delivered (personally or by a system like Pyxis). However, the significant source of emergency department charge capture error is the conversion between dispensed units and HCPCS code billable units. With the high cost of many drugs, inaccurate conversion of dispensed to HCPCS billable units can be an expensive mistake. You can spot these errors most easily on the bill. If you’re seeing charge units of 1 or 2 on the UB04, under revenue code 0636, take another close look to confirm you have not underbilled the units of service on the claim.

Orders Matter

Another common missed opportunity is nursing personnel providing a therapy and physicians forgetting to place the verbally requested order. Sufficient specificity in orders also causes lost charges. For example, an orthotic order listed only as “apply splint to forearm” requires more detail to be billed properly. A better order would be “apply forearm gutter splint.” Such language would allow the coder to determine that a caregiver created the splint and it is not an orthotic instead.

We’ll dive into other sources of loss and the means for remediation in part two of this discussion.

• Read part 2: Fighting Emergency Department Charge Leakage
• Read part 3: Trauma Activation and the Emergency Department Revenue Cycle

You may also like:

• 10 Steps to Improved Charge Capture: Why Revenue Integrity is a Team Sport