The ongoing tussle between providers and payers over coding practices has played a role in CMS’s recent cuts in physician fees and revised E/M coding guidelines, changes that especially affect reimbursement rates for high-intensity care.

The battle over reimbursement is intensifying as the impact of billing codes on physician payments becomes inescapable.

One of the premier arenas in which payers and physician groups clash over reimbursement is high-intensity billing.

Among the reasons is, one, the fact that the amount of this billing has increased sharply; and, two, the fact that medical realities of modern emergency departments are not being adequately conveyed by billing codes.

d2i’s rich and reliable data sets, containing data from more than 30 million ED and inpatient visit records, show that a lack of inpatient beds and ED crowding have necessitated more intense and more prolonged treatment within the ED, treatment that historically would have been done in an inpatient setting. Emergency medicine billing codes are simply not set up to capture the complexities of care in this difficult care environment.

A recent study of US emergency departments by Janke et al. found that the percentage of treat-and-release visits entailing high-intensity billing rose sharply from 4.8% in 2006 to 19.2% in 2019. These high-intensity visits were coded with “high complexity” CPT code 99285 or “critical care” CPT codes 99291 or 99292 and were used for patients released from the hospital.

The authors found that only about half of the increase in high intensity billing can be attributed to changing case mix — such as the fact that the proportion of visits by older patients with more comorbidities and chronic disease also increased during this period.

The Tug of War Between Payer and Provider

If 47% of the increase can be attributed to case mix, what accounts for the rest of the surge?

The study regards upcoding as one possibility — one that payers are certainly concerned about and focusing on. Submitting highly complex codes that misrepresent a patient’s condition may, if determined to be fraudulent, incur the penalties of hefty fines and exclusion from payer programs.

But the researchers worked with only basic claims data such as age, sex, and diagnosis codes, which are only a small part of the entire patient-care picture. Important data like social determinants of health and the clinical complexity of care were not included.

Fine-tuning health care policy “to better calibrate emergency care billing with value must account for what’s missing in these simple measures,” study coauthor Alexander Janke told Medpage Today. He says that in the future, researchers should use enhanced data sets that better represent the increasing complexity of emergency care. In addition to deeper structured data, coders must incorporate more understanding of the medical decision-making process from unstructured text in provider notes. Together, these types of data help support the complexity of individual cases and, therefore, higher coding.

To understand the changes, he stresses, one must also understand how emergency care and the entire healthcare ecosystem have changed. Emergency departments have evolved to offer more services. With fewer resources, they are continually seeking innovative new ways to safely manage patients so that fewer hospital admissions are necessary.

One example is the use of advanced imaging studies to diagnose patients suffering acute abdominal pain, a common complaint in the ED. Visits for nonspecific chest pain are also now being handled with diagnostic testing that is faster and more accurate than previous methods, making it possible to safely discharge patients once certain possible causes have been ruled out.

The Need for Meaningful Data

The ongoing tussle between providers and payers over coding practices has played a role in CMS’s recent cuts in physician fees and revised E/M coding guidelines, changes that especially affect reimbursement rates for high-intensity care.

Simple claims data don’t capture the increased complexity of care for ED patients who are treated and released. As Janke et al. contend, payers need to recognize “the increasing complexity of care” for ED patients who are now “older, more comorbid, and clinically undifferentiated”—and that it is precisely this more-complex care that improves outcomes and enables patients to avoid hospitalization and be discharged safely.

But how to make the case?

Physician groups are understandably upset about the payment cuts, arguing that the result will be less access to care for those who need it most. How can physician advocacy groups more effectively dispute accusations of upcoding and convey the full reality of patient care in the ED?

Studies based on CPT codes are not the answer; these simply don’t convey all the relevant details of care that negotiators need to have on tap in order to negotiate most effectively.

The answer is better data capture, including narrative data.

ED physicians can certainly tell the story of what they are observing every day. But they must tell their stories with the right data on hand. At d2i, we provide the concrete structured and unstructured data that emergency physicians need to tell their side of the story as fully and persuasively as possible.

Contact us or request a demo of our performance improvement analytics to learn more about how we can help you do that.