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Coding Corner: Don't Send Your ED E/M Reimbursement for a Nosedive

Improve 3 billing hot spots to shoot payment through the roof

Confusion about E/M coding, conflicting rules on infusion and injections, and inconsistent guidelines for reporting orthopedic care can cripple your accounts receivable in the emergency department. Follow these expert tips to turn these reimbursement weaknesses into payment strengths.
Streamline Your E/M Coding
Hospitals lose reimbursement for loads of billable services when they don't report evaluation and management (E/M) codes correctly -- which isn't always an easy task, considering many facilities have subjective methods for determining E/M codes. And the more subjective your set of guidelines -- or "tool" -- the more problems you have with assigning the appropriate level, says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, Fla.
"My recommendation is to have as objective a tool as possible" to govern how you assign E/M codes,  Marsh says. "If you can clearly delineate why you chose a particular level, nurses or coders will be more aggressive in assigning the correct code." If the distinctions between different E/M criteria are less clear, staff will choose the lower of two codes because they fear they won't be able to justify the higher code.
Marsh says that most hospitals code conservatively when reporting E/M services, and that many are undercoding in this area. "There is a predominance of levels two and three, and critical care is underutilized."
If you look at the distribution of your E/M codes and feel they don't accurately reflect your patient population, don't be afraid to modify your E/M guidelines, Marsh says. But if you do change your tool, be sure to take a critical look at the outcome. "I have seen people change their tool thinking it was going to get better, and it got worse," Marsh says. "So within the first few months of changing the tool, you need to compare it to where you were before, what you expected the tool to do," and whether it gave you the result you needed.
She stresses that the E/M tool should be an evolutionary process, not a rule book written in stone. If a change you make doesn't work, change it again and evaluate again, and so on, until you secure optimum results for your facility. "That's critical in maximizing your revenue in the emergency department," Marsh says.
You need to use three main criteria when developing your E/M guidelines, according to CMS. Make sure your guidelines meet the following requirements:

 
They are based on facility resources. CMS has been very clear that they don't want your codes based on physician resources, Marsh says.
 
You're not "double-dipping." "Double-dipping means that you should not take [...]

- Published on 2004-03-09