The Dangers of “Downcoding” in Emergency Medicine

February 23, 2017 11:37 am

For a hospital’s emergency department (ED), increasing financial efficiency largely depends on clinical throughput. By segmenting the ED visit into three parts—arrival, in-room, and disposition—healthcare finance leaders can begin to analyze the financial ramifications of specific process improvements that improve patient flow and enable better care to a higher volume of patients in each part.

Before making any changes to ED operations, however, finance and ED leaders can capitalize on one area of opportunity that does not involve patient flow: documentation. At most EDs across the country, there is an opportunity to improve care, decrease risk, and increase revenue by focusing on documentation practices.

The culture of emergency medicine, not surprisingly, perceives certain types of emergent situations as “routine emergencies,” downplaying the efforts necessary to stabilize acute patients. Although this culture has evolved for good reason—namely, to help the ED team maintain cool-headedness in times of great stress—it often is responsible for the gap between the care actually performed and the care documented. That gap is perhaps the most common, and costliest, cause of incomplete documentation and lost revenue in the ED.

Consider, for example, the consequences of a physician’s failure to document the total amount of time he or she spends evaluating a patient with an acute impairment to a vital organ system. This lack of documentation makes it impossible to accurately code for that critical care—one of the most commonly underused code sets. Alternatively, say the physician documents the hour spent stabilizing the patient but fails to document the 20 minutes spent an hour later reviewing the patient’s labs and radiographs, or the 25 minutes after review spent communicating the patient’s needs to the medical staff. Omitting documentation of those 45 minutes of critical care time means a lost opportunity to code for not one, but two segments of CPT code 99292—a loss that translates to a payment that is about 20 percent less than it should be.  More importantly, for the rest of the healthcare team that will care for this patient, the emergency physician has not painted the complete picture of what transpired in the ED.  

Or consider this more common example: An emergency physician treats a patient with asthma who is in respiratory distress. The patient receives life-saving treatments in the ED and improves significantly. Because this scenario is so routine for emergency physicians, the outcome (a stable patient, no longer in distress) could lead the physician to underestimate (and undervalue) the critical nature of the role he or she played delivering outstanding patient care. If a single physician fails to document his or her critical care time in that instance, the difference in payment could be $75 or more. If physicians in an ED with an annual patient volume of 50,000 annual miss even 2 percent of their opportunities for appropriate critical care documentation and coding, that equates to a loss of $75,000 just on the professional fees. If we consider noncritical care charts that were similarly “down-coded” for incomplete documentation, it amounts to several hundred thousand dollars annually in missed professional revenue.

A meaningful gain in financial efficiency, then, comes from changing the “routine emergency” culture around documentation.

The first step is to invite the scrutiny of a coding and billing expert, or to work in tandem with the hospital’s billing company to identify those gaps between care performed and care recorded. A coding expert will be able to quickly point out where a physician has documented one thing but the timing and other factors indicate another.

The second step is to show those discrepancies to the ED team (in this case emergency physicians) and explain how that documentation puts the patient and emergency physician at increased risk, and costs the hospital money, which can in turn deprive the ED of much-needed resources. It is crucial to provide similar documentation education to the nurses, as nurses do so much of the work on the facility coding side. In fact, the missed facility revenue is several times the professional amount. For example, hospitals have been incompletely communicating care and leaving money on the table for years due to faulty documentation around IV administration and medication injections, which require the recording of both start and stop times for billing.

Bringing about a change in ED culture around documentation is feasible only if physicians are able to clearly tie the value of better documentation to the improved ability to deliver high-quality care.. This idea should never be foisted upon physicians. Rather, they should be provided with the data and space required to formulate their own conclusions, and the underlying premise might best be presented to them by a physician champion who also is a respected colleague.

Kenneth J. Heinrich is a senior vice president and group medical officer with Schumacher Clinical Partners, Chicago. 


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