10 ED Mistakes

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

Its output will only be as accurate as the accuracy of its initial set-up. One question to ask, does it the EMR utilize 1995 or 1997 E/M guidelines? CMS has granted an indefinite grace period that allows physicians to use either the 1995 or the 1997 versions of the guidelines.

10 Mistakes Index

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Are you capturing your time based procedure / service codes?

Even though the Emergency Department E/M Levels (99281-99285) are not based on time, there are certain CPT codes that are time based.

10 Common Mistakes Index

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

First of all, the templates should capture quality patient care. Secondly, the templates should capture appropriate documentation for the services provided.

Many templates are based on the presenting complaint

This type of structure is used very frequently by an Emergency Department. Any type of templates used by a physician should be geared to capture:

1. the history
2. exam
3. and medical decision making

They should also capture any nurses notes utilized during the patient visit.

If creating your own internal templates and forms, the layout should be designed to assist staff with capturing their services performed.

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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.

The point system needs to be interpreted and implied in a consistent manner. Therefore, if your billing is being done internally or if an outside vendor is performing your billing, both of those entities regardless of whom it is, needs to interpret your internal guidelines for the point system in a consistent manner.

10 Common Mistakes Index

Tags: 10 ED Mistakes

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.

Your Point System should correlate with the resources utilized to provide a given service such as employee wages, employee benefits and facility costs. In summary, the ED Facility code should reflect the intensity of the hospital services that is provided.

10 Common Mistakes Index

Tags: 10 ED Mistakes

#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.

#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.

#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.

#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.

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

Are you capturing your time based procedure / service codes?

#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.

#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”.

#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.

#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.

#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.

Tags: 10 ED Mistakes

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.

This is simply not true. The Physician E/M Level is based on the Physician’s documentation according to either the 1995 or the 1997 E/M guidelines, which includes the history, exam, and medical decision-making components.

By comparison, the Facility Level is based on documented resources and staff utilized by the department in conjunction with an appropriate point system. (We’ll discuss what an appropriate point system consists of in our next blog). Therefore, the Physician Level of service does not need to be the same as the Facility Level of service.

Two Separate, Yet Necessary, Services

Try thinking of it as two separate, yet necessary, services that occurred at the same event for the same client, but with two unrelated measurement systems being utilized in determining how to best account for what was expended by each in the process. The notion that somehow the two must be billed at the same level is clearly a misnomer, yet is thought to be true by many more practitioners today than one would imagine. The end result leads to the loss of legitimate, appropriate revenue capture for no other reason than to maintain the same billing level between each, regardless of actual services performed.

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