Using advanced data analytics to identify coding outliers and focus on coding compliance can help make for cleaner claims and fewer denials.

With EDs facing revenue cycle challenges, a data-driven approach can provide stability during uncertain times.

During the early stages of the pandemic, emergency departments dealt with an average 42% decline in visits, according to CDC data. Since that time, some volume has returned, but most EDs are still well below pre-pandemic levels. In this time of shrinking margins and operational challenges, it is critical for health care organizations to tightly manage the revenue cycle.

Any discussion on revenue cycle is just not complete without mentioning the No Surprises Act interim final rule with comment period. This rule establishes new protections from surprise billing and excessive cost-sharing. It also presents some major hurdles for provider groups, especially smaller groups that provide specialty services like emergency medicine, radiology, and anesthesia.

The No Surprises Act will only increase the challenges for medical groups hoping to optimize appropriate reimbursement. The American Journal of Managed Care predicts that physicians who surprise bill will likely end up lowering their fully billed charges and are projected to see sizeable reductions in income.

Here are six areas where improvements, guided by advanced analytics, can help mitigate the effects of the No Surprises Act as well as bad payer behavior.

1. Documentation improvement: Capturing all patient information at the time of the visit leads to cleaner claims and fewer denials. This includes listing all complications or comorbidities (CCs), and major complications or comorbidities (MCCs). Underreporting of these conditions is common, especially in an acute emergency setting. Inaccurate risk adjustment results in higher-than-expected mortality rates, longer lengths of stay, and lower hospital quality ratings. Mortality, readmissions, and other outcome measures are linked to CMS value-based payment programs and significant amounts of annual revenue.

2. Coding compliance and identification of outliers: Insurance denials represent lost and delayed revenue, slowing down the revenue cycle and resulting in greater collection costs. Some of the most avoidable reasons for denials are data-related and can be prevented with the right tools in place. Missing information, incorrectly bundled codes, missing modifiers: All of these contribute to denials and can be flagged immediately using analytics designed for emergency medicine.

3. Monitoring time spent per visit: Beginning with the CPT 2021, time, by itself, may be used to select the appropriate E/M code level when counseling and coordination of care dominate the service. When prolonged time occurs, the appropriate prolonged service codes may be reported. This requires physicians to accurately document the accumulated time spent in the medical record.

4. Documenting the impact of social determinants of health (SDoH): Capturing SDoH data for ED patients can reveal important trends that inform value-based care decisions. Many hospitals are increasing utilization of Z-codes for SDoH. These are added to billing that tracks SDoH information. Although these codes are not directly tied to reimbursement yet, they are used to guide care improvements such as prevention of readmissions, referrals to other services, and other value-based initiatives.

5. Training physicians on new coding rules: With the pandemic, telehealth coding rules were relaxed for ease of implementation and to meet the needs of the public. Most of those changes have become permanent, and telehealth and remote patient monitoring are here to stay. In fact, new therapeutic monitoring codes are listed in the 2022 Physician Fee Schedule, allowing for virtual check-in, or audio-only services. If those services are being used in the ED, or by other outpatient and inpatient providers, then education must be pushed out to maximize the correct coding of services.

6. Medical decision-making (MDM) documentation. MDM, history, and exam are the three components of E/M services. In order for the coder to correctly select the MDM, the physician must correctly document:

  • The number of diagnoses
  • The amount of data reviewed
  • The risk of complications or mortality from the presenting problem, diagnostic tests ordered or treatment options

MDM data is most often in the form of narrative data in the notes, making it difficult to extract and analyze. At d2i, we harvest this unstructured data from physicians’ notes and organize it with structured EHR data for advanced performance analytics, revealing important insights.

As EDs recoup from 2020 and 2021 losses and tighten their purse strings, maximizing every revenue dollar will be at the top of the list. Most face the problem of how and where to start.

d2i can help narrow down the problem areas and home in on the most impactful areas for an individual organization. By applying advanced performance analytics tools that reveal problem areas, specific action plans can be implemented that lead to ED sustainability in the years ahead. Contact d2i to learn more.