Complete and accurate documentation and coding are crucial to ensuring appropriate ED reimbursement for both facilities and providers.
While reimbursement rates vary based on facility type (CAH vs PPS), location and payor, there are
substantial increases in payment rates as the level of care complexity increases. Using Medicare
National APC payment rates to illustrate, the payment increase between facility levels is shown below:
| CPT | Description | % increase in reimbursement with level change |
|---|---|---|
| 99284 | ED Visit Level 3 (99283) to Level 4 (99284 | 55% |
| 99285 | ED Visit Level 4 (99284) to Level 5 (99285) | 45% |
| 99291 | ED Visit 5 (99285) to Critical Care 1st 30 to 74 minutes (99291) | 38% |
Payers see only what is submitted on the patient claim and have only the diagnosis and procedure codes to tell the clinical care story. Do your claims stories support optimal reimbursement or put you at risk for downgrades, denials and delays in payment?
Many payors are utilizing AI to automatically downgrade ED levels 4 and 5 to level 3 resulting in reduced reimbursement. These often are unrecognized by providers, as they are not identified as denials but only as a level of care changes that are posted automatically to a contractual adjustment.
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.
Closing the gap to protect ED reimbursement requires:
- An effective facility visit level tool that adheres to CMS guidelines
- EMR Templates that prompt for critical care documentation – including total critical care time Accurate coding to reflect both the acuity of the patient and the care provided. Codes must be complete, accurate and as specific as possible for all treated diagnoses, reasons for visits and external causes of injury.
- Completed and accurate claims submission
- Regular audits to assess the accuracy and completeness of documentation, diagnosis codes, facility- and professional-level charges, procedures, and ancillary services.
- Routine reviews and appeals for level of care changes.
Engage our coding experts at EqualizeRCM to ensure critical care, and help your team close the gap in emergency department reimbursement with our audit and education solutions.