Providers, Payers In Ongoing "Tug-of-War” Over ED Coding, Study Says

There has been a significant increase in high-intensity billing for emergency care services over the last decade, according to a new study published in Health Affairs.

The observational study of US treat-and-release emergency department (ED) visits using data from the Nationwide Emergency Department Sample found that the share of these visits with high-intensity billing rose from just 4.8 percent in 2006 to 19.2 percent by 2019.

The study’s authors expected about half of the increase in high-intensity billing for treat-and-release ED visits considering the data showed, during the study’s timeframe, higher proportions of visits for older patients, those with more comorbidities, and those with non-specific but potentially serious diagnoses.

Of the observed growth, 47 percent was expected based on “change in administrative measures for patient case-mix and care services,” they wrote in the study.

The rest of the increase in high-intensity billing for some emergency care services may be from changes in coding behaviors, the authors admitted. Upcoding, a correction for historical downcoding, and an increased focus on revenue cycle management after years of rudimentary coding and management practices, especially for EDs run by independent hospitals, may have contributed to higher-level ED visits despite fewer patients being admitted to the hospital.

“Coding practices have become one element of an ongoing tug-of-war between payers and providers,” the authors stated.

EDs are now facing reimbursement reductions after CMS recently finalized a reduction in the Medicare Physician Fee Schedule conversion factor, which “would disproportionately affect reimbursement rates for high-intensity care,” according to the study. EDs are also likely to see lower commercial rates after the implementation of the No Surprises Act.

Meanwhile, the study pointed out that CMS identified emergency medicine evaluation and management codes as “likely undervalued” in the 2018 Physician Fee Schedule final rule.

ED coding is a hot-button issue as hospitals face lower reimbursement rates, but coding behavior is just one piece of the puzzle around high-intensity billing for emergency care services, the study stated.

“To frame increasing high-intensity billing as a consequence of either changes in patient presentations or changes in billing practices would be to set up a false dichotomy that fails to acknowledge the substantial evolving role of the ED in care delivery,” the authors wrote.

For example, many EDs now have advanced imaging studies to diagnose patients with acute abdominal pain, which has become the most common primary diagnostic grouping by 2019, surpassing musculoskeletal complaints. There are also accelerated diagnostic protocols using increasingly accurate biomarkers that allow for the discharge of patients with the other top reason for ED visits: non-specific chest pain.

Researchers also pointed to the growth of clinical pathways and observation care for “common but potentially dangerous chief complaints,” which may channel more low-acuity complaints to urgent care centers. Greater mobilization of resources in the ED could also be leading to more intense emergency care, especially for visits that do not result in admission.

“These changes might not always be apparent in simple claims data elements, as some important comorbidities—such as patient frailty or unstable housing requiring more complex care—may be less well captured in diagnosis codes,” the study stated.

While the tug-of-war is ongoing between payers and providers when it comes to ED coding, payers “must acknowledge the increasing complexity of care for a treat-and-release ED patient population composed of older, more comorbid, and clinically undifferentiated patients, to avoid hospitalization, ensure safe discharge, and improve acute care outcomes,” the study concluded.