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The Business of Emergency Medicine: From Care to Compensation

Payment for patient care services is a bit of a “black box” for most emergency physicians who have not carefully tracked how their patient encounters turn into income. It may seem removed from residents in their training, but will soon become a reality from the moment you become attendings. This is a brief look inside the box, starting with the process from point of care to the filing of a “claim” or patient bill.

The effectiveness of billing, coding and collection is affected by many factors beyond the scope of this article. Here, we will focus on the movement of your encounter information through the billing process, or how your chart turns into a bill and then into payment.

How documents or electronic data travel and how they are handled by the billing entity will vary somewhat depending on whether the practice does independent billing, is in a direct compensation relationship with the hospital, or works in a faculty practice plan or larger medical group. However, three essential components will drive the process regardless of the entity doing the billing: a complete medical record, a registration document, and an ED log or other independent source to control for lost charts.

When you see a patient some of what happens during the encounter is documented in the hospital’s medical record system by way of an EMR, transcription or paper record. The purpose of the medical record is not just to bill, but to facilitate continuity of care beyond the ED. Never forget this. The record must first facilitate good patient care. A good medical record also prevents some lawsuits and makes those that are filed more easily defended. Unfortunately, much ED record keeping these days, especially by EMRs and templates, makes good patient care incidental to other interests.

When you defend against audits of your billing — and payer audits are inevitable these days — the payer will not be swayed by your exhaustive description of multiple irrelevant exam findings or templated ROS statements that make every patient look the same. You will be better served by how thoroughly your record describes what was done and why. So “think in ink:” use your charting system in the way that best captures your thought process and decisions.

The patient encounter generates at least a triage record, nursing notes, a physician chart and a billing registration. Most EDs also use log systems for tracking patients, an independent source to control for missing charts. On average, 3-8 percent of ED encounters don’t make it into the billing system on the first pass. Without a chart reconciliation process that matches missing records with the ED log and registration information, you will lose revenue. Treat every chart like an undeposited live check; don’t leave it unaccounted for in the billing process.

The triage record and nursing notes are very helpful ancillary documents that tell a more complete story of the patient encounter, but must never be relied upon to tell the most important parts — what was wrong, what was done and why. Billing for the physician’s professional fee must be done solely from the physician’s record. However, competent billers can use nursing notes in ways that will affect payment in certain circumstances, so it is useful to make these part of the billing packet.

Once the three basic record components (chart, registration, ED log) are created, they must be transferred into the billing process — electronically, if there is an interface between the billing entity and the hospital, or on paper. We call these combined records “billing packets.”

These packets are then indexed, matched and reconciled by the billing entity to assure that they include all that is needed for accurate coding and billing. Patients who left before treatment, those seen by a private physician, duplicate charts and hospital no-bills (VIPs, employee health, or other special arrangements) are checked off from the log and missing charts are put on a “shortage list” to be tracked down and brought back into the process. Hint: if your group is never advised about missing charts by the billing entity, it is likely that this process doesn’t exist or is broken and needs to be fixed. Billing packets are probably being lost.

Common reasons for missing charts: 1) No physician record at all. For example, the chart is “locked” by the EMR and awaiting someone’s final action before it can be pushed to billing, the transcription never made it back into the medical record, the ED record was never uploaded to the hospital-wide EMR, etc. 2) Incomplete physician records, such as a missing physical exam, a missing addendum after labs came back, etc. 3) Electronic conflicts in the transfer process — lost files are very common when sending chart packets out of the hospital and not uncommon even when billing is done internally.

Next, the registration information must be analyzed to determine who is responsible for the bill and insurance must be verified to determine coverage. Insurance information is checked against databases and bill streaming is set up so that claims go to the proper party in the proper order.

In ED billing, the patient with insurance should be billed for the copay or deductible amounts, but should not be considered the first source of payment for the total bill. Claims should go first to the insurer, and billing must be sequenced accurately. Payments from patients who are billed for what the insurer should have paid are normally lower than those obtained by pursuing the insurer for its contractual obligations.

The chart must be coded to capture all service fees before a bill to the patient or insurer can be generated. The 1997 HIPAA laws mandate that all payers use the American Medical Association’s Current Procedural Terminology (CPT) system to determine compensable services. Payers may choose not to pay for certain CPT services, but this is still the universal standard for reporting services rendered.

Fees are established, and RVUs (Relative Value Units) are assigned for each of the more than 400 common CPT codes used by emergency physicians. These codes are reported on the Health Care Financing Administration (HCFA) 1500 paper claim form or the 5010 electronic transaction, the universal standards mandated by HIPAA. In most locations, 75-85 percent of all ED claims can now be filed electronically. CPT codes are used by payers to determine the amounts they are willing to pay for each service.

Diagnosis codes (ICD-9 CM) must also be reported on the claim to identify the reasons for treatment — another HIPAA mandate. Payers audit claims for mismatches between diagnosis codes and services and reduce payment if the diagnosis does not support the reported service.

For example, if a scalp laceration was repaired on a patient who had a syncopal episode, the claim would contain a diagnosis of syncope (ICD-9 780.2) as the reason for the visit level (commonly CPT 99284 or 99285), and a diagnosis of open wound of the scalp (ICD-9 873.0) would be reported as the reason for the laceration repair code (14 different scalp repair CPT codes exist depending on length, depth, and complexity).

If the claim contained only the syncope diagnosis code or matched that ICD-9 code to the wound repair, the payer might respond that syncope alone was not proof that a scalp wound occurred and deny payment for the laceration repair. Much of the down-coding, denial, and delay in claim payment is a result of bad behavior by payers who make up clinically unsupportable diagnosis screening rules, but sometimes the problem is just poor coding.

Coding is the process of understanding the words of the physician and classifying the history, exam and medical decision-making to support the level of care billed — along with any procedures performed — and assigning diagnosis codes that clearly indicate the reasons treatment was provided at the reported level. Every ED visit is given a visit level (99281-99285), critical care (99291) or observation care (99218-99236) code. About 10-15 percent of ED patients also receive procedural services like wound care, ortho management, sedation, debridement, foreign body removal, etc. Many emergency physicians also bill for EKG, X-ray and ultrasound interpretations. Billing for interpretive services is sometimes politically charged, since it can conflict with the billing of other specialists.

Like each visit level, each procedural service has clinical content associated with it that the coder must be able to locate in the chart to support the claim for that procedure. Coders must understand what constitutes sufficient proof of the performance of a particular service and how that service is distinguished from others performed in the encounter. Payers might also have to be educated about the clinical content in the chart, as they often misunderstand (or deliberately ignore) the reasons emergency physicians do what they do.

Each CPT code has a fee assigned to it and RVUs associated with it that are established by Medicare and revised and published annually. Practices that reward productivity often pay based on the production of RVUs. Improving your RVU production is often a function of documenting more clearly so that the coder can understand your evaluation, management, decision-making, and thought process and assign the correct codes.


Author: James R. Blakeman is the Senior Vice President at Emergency Groups. This article first appeared in Common Sense.
Edited by Stephanie Gardner, MD, AAEM/RSA Vice President; and Leana Wen, MD MSc, AAEM/RSA President



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