10 Common Mistakes Managing Emergency Dept Reimbursement and Cash Flow

#1 Believing that the Evaluation and Management [E/M] level billed by the ED Physician must be the same level as that billed by the hospital for the ED Facility.

The #1 Most Common Mistake occurs when your staff believes that the Evaluation and Management [E/M] level billed by the ED Physician must be the same level as that billed by the hospital for the ED Facility.

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#2 Failing to evaluate and adjust your Point System on a systematic basis.

The 2^nd most common mistake is that the Facility Point System is not regularly evaluated to capture all services. A point system would be a consistent methodology for assigning an ED Facility Level based on the work performed by the ED staff. An interesting fact is, that to this date, there are no national standards for assignment of hospital Facility Levels.

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#3 Failing to consistently educate all members of your ED staff regarding your Point System

A 3^rd common mistake is the inconsistent interpretation of the point system by the staff. Once the point system is developed, it is imperative for all staff members to accurately and consistently interpret not only how the point system is being used, but also how it was intended to be used.

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#4 Overlooking to regularly review and update all of your documentation templates

The 4^th common mistake occurs when your documentation templates are no longer capturing all services appropriately.

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#5 Failing to document the length of time used for your time based services

Are you capturing your time based procedure / service codes?

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#6 Choosing and then utilizing the wrong [E/M] guidelines for your ED

The 6^th common mistake for revenue capture is relying solely on your EMR to capture the appropriate E/M Level.

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#7 Not automatically updating your fee ticket/superbill annually

The 7^th common mistake occurs as a result of your Fee Tickets / Superbills not being updated on a regular basis.

Updating the fee ticket should really be an ongoing process, but unfortunately, we find that this is a lost discipline in many instances. The reason it must be an ongoing process is because the codes that are utilized for billing are revised twice a year. On January 1st, the CPT and HCPCS codes are revised; this includes additions, deletions and revisions to verbiage. Then again on October 1st, the ICD-9 diagnosis codes are updated with additions, deletions and revisions.

A very typical scenario that we frequently observe is when hospital employees become too busy with day-to-day activities, they can become consumed just with running their departments. The process of revising and updating the fee tickets is a low priority, and consequently can be overlooked or placed on the back burner.

A few of the problems symptomatic of outdated fee tickets are:

1. Delayed payment of claims,
2. Increased denial of claims,
3. Increase of “no payments”.

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#8 Not conducting chart reviews on a regular and consistent basis

The 8^th common mistake in managing cash flow is due to the lack of chart reviews / audits.

A BDA coding review includes taking a thorough look at the documentation of each particular visit to ensure that the appropriate level of the ED code was billed along with any other billable services. We perform chart reviews for our clients either quarterly or twice a year. Again, this is an item that is frequently shuffled off to the side because of the hectic daily schedules of running an Emergency Department.

BDA Coding reviews include:

Documentation of the entire encounter; the physicians notes, the nurses notes, and any of the ancillary documentation that corresponds with each visit.

The corresponding fee ticket. The fee ticket is important because it indicates what services are being captured by the provider/staff or not being captured by the provider/staff for charge processing.

The corresponding claim forms. The claim form identifies which charge elements are actually being submitted or not being submitted to the outside world for payment. Often there are numerous issues that can be identified from this type of review. One issue that might be identified would be charges that actually do not match the encounter documentation. A second issue that might be identified would be that there are billable services that are not separately charged for. A third issue would be incorrect information in the charge master. A forth issue would be duplicate billing from different departments. This is identified by different revenue codes representing the same service. A final issue that might be identified in a claim form review would be incorrect utilization of modifiers in and units.

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#9 Failing to show your providers [E/M] Bell Curves that compare their coding to that of their peers on a National Benchmark.

The 9^th common mistake that can impact reimbursement can occur when your provider does not know where he/she falls on a National E/M Benchmark Bell Curve.

E/M Benchmark Bell Curves can contain powerful information. Bell Curves provide a great snapshot of what actually is going on. They can identify if providers understand E/M documentation and guidelines.

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#10 Experiencing the same mistakes over and over as a direct result of not providing ongoing training and coaching for your providers and staff

The 10^th common mistake that will often affect revenue is an ongoing lack of education for all of your Providers and Staff. They should each receive focused instruction as a direct result of ongoing and consistent chart reviews.

BDA meets one-on-one with each physician to review their documentation and code assignment on every encounter to discuss the findings and provide specific education and recommendations. BDA also meets with the department staff and coding staff depending on the issues that are identified in these reviews.

In summary, the BDA program develops a customized approach that addresses each area of opportunity for the client.

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