EqualizeRCM’s Audit Team conducted a comprehensive audit of coding and billing practices for 99285 and 99291/99292 in the Emergency Department setting of a Critical Access Hospital. Our audit demonstrated that there are many challenges and pitfalls when documenting ED critical care encounters.
Our study parameters:
- 223 encounters audited
- 672 ED E/M and codes analyzed
The overall accuracy score for CPT E/M levels was 62%. Fully 38% of claims were submitted incorrectly as a result of poor documentation and data collection.
- Eighty-five accounts rebilled with additional charges.
- $74,800.66 increased potential revenue.
- Twelve accounts past timely filling with loss of $10,103.41.
Under-coding usually is not a significant problem in the ED setting. However, because the facility did not have good documentation; i.e., notating the critical care provided by the facility staff and capturing the data correctly, they lost $84,904.07 or $381 per encounter audited.
Our recommendations to this facility, and anyone else billing and coding critical care, included:
- Educate Providers/Staff on critical care criteria.
- Build critical care charges for both facility (450) and providers (981).
- Create Facility critical care policies and charge sheets for complete charge capture.
- Build EMR templates that include space for providers to document total critical care time.
- Conduct monthly audits of all critical care charts to ensure that charges are being captured correctly.
- Conduct monthly audits of 99285 Level 5 visits transferred to higher level of care to assess missed opportunities for capturing critical care.
If your ED has not been audited recently, let the EqualizeRCM coding experts perform an audit and help educate your staff on ensuring the capture of ED critical care and protecting your reimbursements.