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Could National Hospital ED Coding Guidelines Also Influence Pro Fee Side?

Could National Hospital ED Coding Guidelines Also Influence Pro Fee Side?

The Medicare Payment Advisory Commission (MedPAC) made it official with a vote at its April meeting: The group will draft a recommendation that Congress direct the U.S. Department of Health and Human Services to develop and implement a set of national guidelines for coding hospital emergency visits by 2022.

Medicare has already proposed and implemented changes to outpatient office visit coding, and it is no surprise that such changes will be implemented on the facility side. The current focus is now on the facility side where hospitals are currently permitted to develop their own guidelines for reporting ED visits based on methods established by the American Hospital Association and American College of Emergency Physicians. However, all providers should monitor this trend. We won’t have to wait long for the ripples to spread – 2022 is practically right around the corner.

In recent years, ED coding has shifted from lower to higher intensity services for a variety of reasons – some of which appear to have been unsubstantiated. In a presentation to the commission during the April meeting, members Carolyn San Soucie and Dan Zabinski described how the percentage of Level 4 and Level 5 ED visits dramatically jumped from 2005 to 2017. In the same time period, Levels 1 and 2 ED visits greatly diminished. The commission’s data analysis revealed that conditions treated in the ED did not change, yet there was an increased use of services; e.g., EKGs, CTs, etc.

Their conclusion was that Medicare payments are likely too high for many patients, and that national coding guidelines would provide hospitals with clear rules to help improve coding ED visits. This also would allow the Centers for Medicare & Medicaid Services (CMS) a stronger baseline for evaluating coding practices in place at hospitals.

What MedPAC failed to consider is that Medicare patients presenting to the Emergency Department have more comorbidities and are increasingly sicker and more unstable than in the past. These patients require more resources and much more extensive workups than they did 10-15 years ago. This is more likely the reason for the shift to increased coding of 99285 visits rather than a change in the way these charts are coded.

You should be thinking about how this could impact your practice. A good place to start is by taking a hard look at your documentation; it is the first line in risk management. Errors at this stage can lead to larger troubles when it comes time to start coding. Getting an outside perspective on your internal processes can help identify weaknesses you may have overlooked and introduce you to innovative ideas. MedData’s team of experts is available to assist you with any coding and billing questions or concerns you may have.

Image credit: Medicare Payment Advisory Commission

About the Author

Dr. Robert Wagner is the Senior Vice President of Medical Affairs at MedData. He has worked with healthcare organizations of all sizes, building consensus to integrate the revenue cycle, IT, coding, compliance, informatics, and care and utilization management to provide sound clinical, operational, and financial outcomes. Dr. Wagner is passionate about making sure patients receive excellent care – clinically and financially. He has helped multiple clients build end-to-end revenue cycle solutions, removing the challenges and ensuring patients and providers have a data-driven, compliant, and integrated financial experience.

Robert J. Wagner, MD, FACEP

Dr. Robert Wagner is the Senior Vice President of Medical Affairs at MedData. He has worked with healthcare organizations of all sizes, building consensus to integrate the revenue cycle, IT, coding, compliance, informatics, and care and utilization management to provide sound clinical, operational, and financial outcomes. Dr. Wagner is passionate about making sure patients receive excellent care – clinically and financially. He has helped multiple clients build end-to-end revenue cycle solutions, removing the challenges and ensuring patients and providers have a data-driven, compliant, and integrated financial experience.

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