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Managing Facility ED Charge Capture: Fundamentals for Success with Evaluation and Management (E/M) Codes

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Managing Facility ED Charge Capture:

Fundamentals for Success with Evaluation and Management (E/M) Codes

In the era of continuing fluctuation with reimbursement, charge capture remains the mainstay of provider and facility revenues. Large failures or defects within the process can quickly cause a significant loss of revenue. Alternatively, small and difficult to identify defects lead to slow revenue leakage. In either case, the outcome is suboptimal. We will cover the basic components in this post.

While you should charge for everything, from routine supplies to costs for staffing and equipment, charges need to be wrapped into billable services to ensure hospitals cover their costs. There are only four services a facility can bill for, which are:

  • Evaluation and Management (we’ll focus on this portion in this post)
  • Surgical and Medical Procedures
  • Supplies (including Prosthetics and Orthotics)
  • Pharmaceuticals

When constructing a charge for a service, all four of these should be considered and included and excluded to ensure the charge capture process is sufficient. We’ll focus on the Evaluation and Management Codes (E/M) in this post.

Despite many association efforts, no singular method was defined to correctly assign a level. In 2008, the Center for Medicare and Medicaid Services put forth 11 guidelines that must be considered in constructing the level for reimbursement. These points can be found in the Federal Register, Vol. 72, No. 227 beginning on page 66805 and are detailed below.

  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 (65 FR 18451).
  2. The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources (67 FR 66792).
  3. The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits (67 FR 66792).
  4. The coding guidelines should meet the HIPAA requirements (67 FR 66792).
  5. The coding guidelines should only require documentation that is clinically necessary for patient care (67 FR 66792).
  6. The coding guidelines should not facilitate upcoding or gaming (67 FR 66792).
  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.”

Despite these documented guidelines from 2008, auditors continue to find that many of these points cannot be produced as documentation during an audit, creating a compliance and reimbursement concern for the facility. Additionally, the median level E/M was a 99283 (Level 3) in 2000 under OPPS but has been trending more to Level 4 (99284) and Level 5 (99285) over the past 20 years. The increasing number of Level 4 and 5 charges being submitted has caused concern, leading to an Office of Inspector General (OIG) review, as well as a PEPPER component to assess why there’s a trend to a higher level, and if it is consistent with the guidelines.

While the 11 points are used for Medicaid and Medicare services, most commercial and managed care payors follow this guidance as well. However, some non-governmental payors have issued their own specific guidelines for facility construct of the E/M level. Many of these guidelines are not consistent with the 11 points above, which can cause operational concerns surrounding compliant billing. One example is Humana Claims Payment Policy, “Emergency Department E/M Reimbursement” which provides specific examples and guidelines on how an E/M must be assigned in order to seek reimbursement from Humana. In this specific guideline, there are not the 11 points as noted for Medicare, but “Minimum Criteria for Acceptance”, which detail what must be documented to obtain a specific E/M level and what facility resources are contained within each level.

Having multiple guidelines requires a robust policy and procedure process to ensure consistent documentation and coding for all payor scenarios. In addition, training should be undertaken with competency testing performed to ensure all personnel can arrive at the same level of service based on the same documentation, thus demonstrating consistent code application.

The most overlooked of the 11 points is number 11, “The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.”

The most overlooked of the 11 points is number 11, “The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.” In many reviews of hospital ED facilities, there are incomplete or outdated policies and procedures. If a “point system” is used, then the matrix for how to assign points based on facility resources expended must be available to the auditors.

In some cases, such as with EPIC and Cerner, there are points calculators within the module such that when documentation occurs, points may be assigned to achieve consistency in application. The concern arises when this calculator is not reviewed on a regular basis to ensure that the points assigned are representative of the services. For example, there could be a new service not represented by a specific CPT code that is not in a calculator because it hasn’t been updated since it was implemented. Points calculators within system software do lead to a consistent application of the codes; however, the resulting “bell curve” for E/M Levels 1 through 5 should be regularly reviewed to see if there is a trend to lower or higher levels of care. This may indicate that the calculators, policies, or procedures need to be reviewed, and potentially adjusted, to fit the current provision of care.

In summary, policies and procedures based on the Medicare guidelines should be created, and each individual involved in revenue generation should be adequately trained on the methodology to capture the charge. Additionally, specific documentation examples should be provided in the procedure such that each service provided (i.e. patient reassessment) has specific measure(s) that must be documented before that service may be counted. So, let’s take a “reassessment” of the patient for example. Internal charging guidelines might state that you need to document three different vital signs as well as the Glasgow Coma Scale. If these are all documented then that is worth 3 points in terms of direct facility resource consumption. Finally, there should be consistent and ongoing audits of records to ensure documentation does, in fact, support the level of patient care provided.