AUTHOR: Gayathri Natarajan, Access Healthcare.
Delivering quality care, while ensuring effective clinical documentation and compliant medical coding is even more challenging in emergency departments, which are fast-paced environments spread across multiple specialties presenting unique medical coding and billing challenges. Alongside knowledgeable clinical staff, specialized medical coders and billers with the requisite experience and strong analytical skills are required to obtain necessary reimbursements.
In this paper, we share our best practices to address medical coding and billing challenges in emergency departments and ensure optimal reimbursements.
Understanding ED Coding and Billing Challenges
- The nature of ED environment demands instant cognitive clinical decisions and shorter execution time.
- Timely Coordination of care between ED physicians and multiple faculty staffs and documentation of the same is pivotal for the coders to distinguish physician/professional services vs facility services rendered by nurses and ancillary staff.
- Longer ED stays are often subject to scrutiny and audits.
Best Practices in ED Coding
The following are some of the best practices from our experience in Medical Coding:
- Recognize that Emergency Departments are at a Critical Intersect of Care: The Emergency Department lies at the intersect of outpatient and inpatient services. The claim cycle, therefore, diverges into two paths a) Professional Coding and billing through CMS 1500 and b) Facility coding and billing through UB 04.
- Understand Key Documentation Attributes that Influence ED level. Irrespective of the type of care (Professional or Facility), it is imperative that the physicians, nursing and support staff capture complete details for all medical services rendered. The facility ED level, on the other hand, is determined by the extent of services rendered by nursing and ancillary staff.
- Educate Physicians on Documentation Requirements. Educating ED clinicians on clinically significant and relevant documentation is key to achieving compliant coding and optimizing end revenue/reimbursement.
- Know Your CPT Coding Rules to Avoid Up/Down Coding. It is important that the coders correctly understand coding guidelines associated with determining the ED level and ancillary procedure codes reported along. The coding rules for ED level on the physician side are driven by the 3 key components – history, exam, and MDM (Medical Decision Making).
- Role of Modifiers in ED coding - the Key to Avoiding Denials. It is important for the medical coders to have the right understanding of the coding guidelines that drive the appropriate modifier selection and avoid non-compliance.
- Understand Commonly Overlooked Coding Guidelines. We provide a list of commonly overlooked coding guidelines.
- Ascertain Diagnosis Specificity to Avoid Medical Necessity Denials. The medical necessity in an ED set up is determined by the severity of patient’s medical condition that necessitated the service to be rendered in an ED set up over a scheduled outpatient visit.
- Critical Care, a Critical Branch of ED coding. These are time-based codes that carry specific coding guidelines with specifications around the frequency of reporting and list of services that are considered bundled.