Claims Adjudication

Avoid ED Claim Challenges by Developing CDI Teams

May 9, 2018 11:17 am

Applying the same rigor to outpatient coding as teams did with outpatient coding during the transition to ICD-10 can help hospitals and health systems avoid reduced ED payments.

Under a new policy effective March 1, UnitedHealthcare is analyzing emergency department (ED) claims that use a level 4 or 5 severity code to review whether the coding is appropriate. If the health plan’s automated audit determines the code is not justified, claims are being down coded, reducing ED service payments.

See related tool: Analysis of an ED Claim

Hospitals and health systems should respond by making sure they are coding accurately, which requires documentation that supports specific evaluation-and-management (E&M) codes, says Sandra Wolfskill, director of healthcare financial policy for HFMA. That means adopting a standard practice on the inpatient side—the clinical documentation improvement team—for use in the outpatient arena.

“The key to survival, if you know that coding and downgrading of E&M codes is going to be an issue, is to get an outpatient CDI [clinical documentation improvement] team together,” she says.

What UnitedHealthcare Is Doing

The health plan’s Emergency Department Facility Evaluation and Management Coding Reimbursement Policy, which applies to commercial plans and Medicare Advantage plans, was prompted by a recent increase in claims using level 4 and level 5 severity codes, according to a spokesperson. Level 4 denotes need for two diagnostic tests (i.e., EKG, labs, X-ray, CT, MRI, ultrasound) and Level 5 denotes three diagnostic tests and special imaging.

Although the number of ED visits nationwide has remained consistent in recent years, the frequency of level 4 and 5 severity codes increased, according to the health plan. “Looking at our own internal UnitedHealthcare claims data, we have seen that, from 2007 to 2016, the use of these codes has gone up by more than 50 percent,” the spokesperson said.

Under its new policy, UnitedHealthcare will use a coding tool to audit level 4 and level 5 claims for ED services. The software evaluates ED level codes in conjunction with other claims data, including diagnosis codes, procedure codes, patient age, and patient gender. Claims that are determined to be inappropriately coded at level 4 or level 5 will be down coded, resulting in reduced payment. Exceptions include claims for the following patients:

  • Critically ill or critically injured patients
  • Children under age 2
  • Patients who are admitted for an inpatient stay or observation

Provider organizations can appeal down coded claims.

ED Coding Issues

Molly Smith, vice president of coverage for the American Hospital Association, says the increasing use of level 4 and level 5 severity codes for ED services may be justified. Among other things, the opioid crisis is filling EDs with patients who have complex medical situations, regardless of the symptoms that prompted the ED visits. “There’s a lot going on right now that is potentially compounding these patients’ conditions,” she says.

HFMA’s Wolfskill points out that more accurate documentation may in fact explain the increasing use of high-level severity codes. “As hospitals have implemented electronic health records, they have been able to prompt physicians to more adequately document what they are doing with the patient,” she says.

AHA and HFMA share UnitedHealthcare’s goal of accurate coding that adheres to the federal government’s guidelines. But AHA’s Smith says hospitals and health systems should not have to buy the health plan’s tool to avoid down coding.

What To Do Now

CDI, a systematic approach to assuring that clinical documentation supports accurate coding, will allow hospitals and health systems to know that their ED claims are being coded appropriately, Wolfskill says. Inpatient CDI became common during the run-up to and implementation of the ICD-10 coding system, but the same level of attention was not given to outpatient services. 

The ED, she says, is the perfect place to start. “If you’re not doing outpatient CDI, you should start,” Wolfskill says.

She advises either redeploying some members of the inpatient CDI team to work on ED—and eventually other outpatient services—documentation issues or using an outside vendor to lead the task. The team needs to understand what coding issues are of concern, what physicians need to learn to code better, and which physicians need individual coaching. Then the team develops and carries out a plan to make the necessary changes.

What not to do. “You don’t want to just run down to the ED and say to the docs, ‘You have to document more,’” Wolfskill says. “That’s not going to change behavior.”

Instead, recruit the medical director and the chief of the ED to be involved in the CDI initiative. “Then you can educate the physicians and the nursing staff about what is required to have adequate documentation in the electronic record to get paid appropriately for what you are doing.”

Lola Butcher is a freelance writer and editor based in Missouri. 

Interviewed for this article:

Molly Smith is vice president of coverage, American Hospital Association.

Sandra Wolfskill, FHFMA, is healthcare finance policy director for Revenue Cycle MAP, HFMA.

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