In recent years, improper Evaluation and Management (E/M) claims have been shown to be “50 percent more likely to be paid for in error than other Part B services,” showing that the industry as a whole has an issue.
According to a Department of Health and Human Services report, Medicare inappropriately paid almost $7 billion for improper coding or claims with lacking documentation in 2010. The interesting thing to note from the report is that these incorrectly coded claims included both upcoding and downcoding, meaning E/M services were billed at levels higher, and lower, than coded.
It’s no wonder then that the Department of Health recommends the following:
- Physicians are better educated on coding and documentation requirements
- Erroneous claims for E/M services are followed up on
- Physician groups are encouraged to have contractors review E/M services billed for by high-coding physicians
This last recommendation, the one that encourages better communication between doctors and their contractors, is one that we at DuvaSawko see hinder Emergency Department practices all too frequently and causes recurring issues with ED coding.
Why Are Emergency Medicine Groups At Risk Of Coding Issues?
The Department of Health’s recommendations above highlight the main areas of concern: it is challenging to keep physicians up to speed on ever-changing documentation as is following-up on erroneous claims.
Perhaps one of the most overlooked, and least talked about issues, is that of choosing a inadequate offshore coding partner. All too often, practices make their decisions to partner with a billing and coding provider based solely on the function of price.
DuvaSawko, for example, is very competitive in this arena but we have noticed there are competitors who deliver pricing on medical billing and coding that is way below industry standard.
The function of coding in emergency medicine is a rather complex one, and as such, practices should have professionals in place who are aware of the ever changing rules, and audits should be performed regularly.
These competitors are able to charge significantly lower rates because they opt to outsource their billing to a company outside of the U.S. The drawback to this is the client is now faced with being non-compliant in their coding and could end up at risk.
Why Do Coding Issues Happen? Coders Get Too Comfortable
In a older yet still relevant piece on For the Record, author Susan Chapman penned an article titled Beware of Poor Coding Habits that shines a light on many of the issues with coding and coders.
One example Chapman provided is that coders “develop a tendency to not dig deep enough into the medical record.” For example, the congestive heart failure (CHF) code is (428.0), but the code for systolic CHF is completely different.
This is just one of many examples of erroneous coding that occurs when a coder scans the record instead of digging deeper to see that the documentation actually says something that is billed at a completely different rate.
Chapman goes on to cite similarly overlooked situations like the above, as well as coders who “get comfortable,” memorizing codes and forgoing resources like software programs or reference books.
Other issues with coders are numerous, and might include:
- Harried coders: those who are in a rush to accelerate the coding process
- Codes searched via the internet but not checked against code books
- Coders that use cheat sheets which are not specific enough for the diagnosis
- Coders who are challenged to meet productivity goals
We can take it one step further and cite that inadequate regular compliance oversight is also a contributing factor. Regardless of the coding issue, one thing remains: inaccurate coding leads to inaccurate reimbursement, and in some cases, legal action against your company.
Ensuring Your Emergency Department Has Accurate Coding
Countering improper E/M coding is a serious issue that every emergency department has to consider and put into action. The Centers for Medicare & Medicaid Services (CMS) guidelines for coding are simple enough to understand, but more difficult to meet:
[I]t would not be medically necessary or appropriate to bill [for] a higher level of [E/M] service when a lower level of service is warranted.
After all, Current Procedural Terminology (CPT) dictates that seven components make up the level of an E/M service, meaning coding can be more complicated and time intensive than many may think.
To improve accurate coding, the Department of Health recommends the following:
- Educate physicians on the requirements of coding and documentation, directly or through the use contractors
- Encourage contractors to prioritize high coding physicians in their review strategies
- Follow up on erroneous claims for both under and over payments
Every ED practice can implement change to prevent erroneous claims internally. Or, if your coding is outsourced you can ask your billing and coding partner the hard questions to determine if they meet the recommendations set forth by the Department of Health and your personal scrutiny.
In the recommendations by the Department of Health above, it is clear they understand many Emergency Medicine groups utilize offshore partners. However, what they are not saying deliberately but which can be read between the lines is that the claims made by any practice are ultimately the responsibility of that practice and not their partners.
Some outsourcing partners, particularly the ones offshore, are much less likely to be in compliance than those based in the U.S. due to their inherent accountability. Rather than hold your practice at the whim of a discount coding and compliance contractor to save a few dollars from month-to-month, think of your long-term goals as a sustainable and compliant provider to ensure accuracy and profitability now and into the future.
At DuvaSawko, All Coders Are Certified In Nationally Recognized Coding Credentials
In the quest to have an impact on the US economy, you can rest assured that all coders are U.S.-based DuvaSawko employees. We don’t use contractors of any kind to get the job done. Our quality control and compliance program was designed to adhere to all relevant standards, ensure staff is properly trained, monitor the constantly changing regulatory environment and implement timely changes to maintain compliance. Contact the team at DuvaSawko today at 888-311-8760 or click HERE to receive your Complimentary Analysis.
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start an emergency department medical practice - 6 easy steps
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