The revenue cycle industry is undergoing significant challenges as payers take advantage of the new coding system to drive down payments. This has resulted in significant volumes of denials that must be managed individually in order to receive at least partial payment for denied claims. In addition, the Emergency Medicine industry has been frothed with significant challenges as more and more uninsured presents to the Emergency Department for treatment and significant numbers of patients remain in Emergency Departments for extended periods of times, often days, with no easy or established mechanism for billing and receiving payment for these unique situations.

The American Medical Association (AMA) continues to revise coding descriptors to address these changes, but payers are slow to pick up on these and continue to deny services that don’t fit into their specialized programs. It is important that several conditions exist in order to assure:

• Number One accurate coding,
• Number Two complete documentation by providers,
• Number Three accurate billing and,
• Number Four attention to payments, reasons for denials, and management of resubmission of claims.

With regards to coding, first things first, coding companies should have errors and omissions insurances to cover any significant coding errors that occur.

With “payor based” coding, this leaves coding companies open to and vulnerable to accusations of coding errors. For examples, CPT has certain coding rules published. Medicare has different clarifications of these coding rules. In addition, Medicare also has numerous Medicare carriers that interpret rules differently; some see things one way, some see things another, so coding company must adhere to local MAC rules to assure accurate coding.

Medicaid and private payors have their own interpretations that are often not published; therefore it is very difficult for coding to be performed accurately without specific rules to follow when they exist. This is why denial management is so critically important. Fortunately, there are not as many rules for Emergency Medicine as there are for other specialties, and so the risk is limited.

By far the biggest challenge is working within payor guidelines and managing extensive denials for payment. Payment denials don’t mean that inaccurate coding has taken place. It is important to know what interpretations of National Guidelines coding companies are following. For examples, The American College of Emergency Medicine Physicians (ACEP) publishes interpretations of the 2023 Evaluation and Management guidelines. Those have been utilized by most of the Revenue Cycle companies that deal with Emergency Medicine claims. However, different payers may interpret them differently, thus denials are generated and must be addressed. As we see payers taking a more militant approach in paying claims we see denials increasing for such things as “level 5” EM visits which can often be down coded to “level 4” and even “level 3”. We seldom see denials for critical care however we can often see denials for Evaluation and Management services with certain procedures. Payers are also prone to look at the final diagnosis for a claim rather than the reason for the visit which, in an Emergence Department can be significant. Therefore, when denials occur for lack of medical necessity, a favorite denial reason for payers, the chart must be reinterpreted and a reconsideration sent back to the payer.

The most significant thing to look for in a coding company is both internal and external auditing of their work. This not only gives the client a much higher level of satisfaction of accuracy but it also provides an opportunity for the coding company to see where their code assignment may differ and for what reasons. Again, Emergency Medicine Evaluation and Management (EM) coding can be very subjective and one needs to know where the subjectivity can create both inaccurate coding and payment issues. Finally, documentation is one of the most important elements of coding as coders select words and phrases from documentation to fit into the appropriate code descriptor boxes so to speak and assign the code.

If coding companies are not working with clients to notify physicians when documentation omissions create a down code or are not generally working with physicians to notify them of changes in documentation requirements, then it is a given that revenue would be affected. At Edelberg we have coined the phrase “Audication” and we have established an “Audication” program to stress the importance of education and audit of both physicians and coders. Physicians must be reviewed for their ability to assure documentation fulfills coding requirement for each level of service. Education of any deficiencies for both coders and providers is a concrete way to continue to address changes in the industry, changes within the institution for available medical record formats, and the ever changing coding world.

So the more pressing questions is how can you not afford to have a coding company as your expert on your team?…something like that😊