What Every Graduating Resident Needs to Know About Reimbursement

Introduction

During training, residents are primarily focused on learning to provide excellent patient care.  Residents may have had some exposure to billing and payment during their training, but these experiences are often varied. This paper covers the some of the basics of emergency medicine coding and reimbursement and is designed to provide the graduating resident some information before entering practice. It is expected that the graduating resident will need more detailed understanding of these issues.  For simplicity, the information has been broken down into the subheadings of Coding and Documentation, Reimbursement and Physician Payment.

Coding and Documentation

When physicians generate a chart for a patient encounter, the documentation is used by professional coders to assign specific patient care and procedural codes that reflect the extent of the evaluation and management of the care, as well as any procedures that may have been performed by the physician.  It is important that the documentation be clear and complete, as these coders cannot make inferences about the care provided.  Similarly, the codes that they generate are used by payers to determine payment. In most cases, the payers do not see any additional information about the encounter.

The language of coders is Current Procedural Terminology, or CPT, which has been maintained by the American Medical Association (AMA) since 1966.   The AMA CPT Advisory Committee, which is comprised of a member from each specialty society, provides guidance to the AMA for annual updates of the codes.  Emergency medicine is represented by ACEP. 

While the CPT manual contains many codes, emergency medicine uses a relatively small number of evaluation and management or E/M codes.  These codes describe the cognitive work that is involved in taking care of the patient. The level of documentation leads to a choice of a specific code by the coder.  The left-hand column of Table 1 lists some of the codes commonly used for emergency medicine encounters. (99281-85) Emergency physicians can also use codes such as 99291 for critical care or Observation codes.  There are other codes for specific procedures, which will not be discussed in detail in this basic overview. 

Table 1. Sample of Common Emergency Medicine codes

CPT Code	History	Exam	MDM	2021 Work RVU
99281	Problem-focused	Problem-focused	Straightforward	0.48
99282	Expanded	Expanded	Low Complexity	0.93
99283	Expanded	Expanded	Moderate Complexity	1.60
99284	Detailed	Detailed	Moderate Complexity	2.74
99285	Comprehensive	Comprehensive	High Complexity	4.00
99291			Critical care, 1st hr	4.50
99220			Initial Observation	3.56
12001			Simple laceration repair	0.84
31500			Intubation	3.00
23650			Shoulder reduction	3.53
93308			Limited cardiac US	0.53

Table 2 provides explanations for the extent of service required for the E/M codes.

Table 2. Definitions of the extent of service for History and Physical Exam elements. (CC = Chief Complaint; HPI = History of Present Illness).

ED E/M Level	99281	99282/99283	99284	99285
History and Physical Exam	Problem focused	Expanded	Detailed	Comprehensive
HPI	Brief (1-3 elements)	Brief (1-3 elements)	Extended (4+ elements)	Extended (4+ elements)
Past Medical/Family/Social History	Not required	Not required	Document review of ≥1	Document review of ≥2
Review of Systems	Not required	1 system	Extended Review (2-9 systems)	Comprehensive Review (≥10 systems)
Physical Exam (can vary by payer)	1 organ system examined	2-7 organ systems examined	2-7 organ systems examined	≥8 organ systems examined

 

Extent of Service	History	Physical Exam
Problem focused	CC, brief HPI	Limited exam of affected part
Expanded	CC, brief HPI + Problem pertinent review of systems	Limited exam of affected part + Other symptomatic or organ system or related body areas
Detailed	Extended HPI + Extended review of systems + Pertinent past, family, and/or social history	Extended exam of the above (generally 5 to 7 body areas or organ systems)
Comprehensive	Extended HPI + Complete review of systems + Complete past, family, and social history	General multisystem exam (8 or more organ systems) OR complete exam of a single organ system

 

It is important to note that the medical decision making, or MDM, is the section of the chart that will likely determine the highest possible code and communicate to the coders the complexity of the patient encounter.  The complexity is determined by three elements:

1. The  differential diagnoses and management options that must be considered;
2. The data and testing reviewed such as labs, EKG’s, or x-rays; and
3. The risk of significant complications, morbidity and/or mortality to the patient.

Table 3 below displays the information that is used by the coders to determine the complexity of the MDM. Two out of three elements are required for a given row to qualify for a specific level of MDM.

Table 3. Complexity of MDM

Complexity	# of Diagnosis and Management Options	Amount and/or Complexity of Data to be Reviewed	Risk of Complications and/or Morbidity and Mortality
Straightforward	Minimal	Minimal or None	Minimal
Low Complexity	Limited	Limited	Low
Moderate Complexity	Multiple	Moderate	Moderate
High Complexity	Extensive	Extensive	High

 

But what about ICD-10 Diagnosis Codes?

The International Classification of Diseases 10th Edition, or ICD-10, codes are used to communicate diagnoses to payers. The ICD codes differ from CPT codes in that they are diagnoses codes, whereas the CPT codes reflect the work that was done during the encounter as described above.  ICD codes line up opposite CPT codes on a bill.  So, for example, a diagnosis of acute tonsillitis would have an ICD-10 code of J03.90, and perhaps a CPT E/M code of 99283.

Many payers use the diagnosis captured by the ICD codes to determine payment for services. For example, some private payers will not pay above a 99283 for a diagnosis of gastroenteritis. However, an episode of gastroenteritis that is severe enough to require intravenous fluid resuscitation for dehydration or cause acute kidney injury, may be coded at higher levels if those diagnoses are documented. Therefore, it is important not only to fully document in the chart the work that has been done, but also to carefully list the diagnoses of the problems that have been addressed during the encounter.

Tips for Documentation

Documentation guidelines were designed by Medicare to define what content is needed for History, Physical Examination and Medical Decision Making.  In emergency medicine, the 1995 documentation guidelines are the most frequently used and well worth reading. ( 1995 Medicare Documentation guidelines )  To ensure that charts are coded appropriately, make sure that all chart elements are performed and documented for the level of the encounter. 

Example: A 99285-eligible encounter requires a comprehensive history. If a complete past, family, and social history are not performed and documented, that chart would be down coded to a lower level of service. Likewise, if the ROS was not complete, the documentation would only be able to support an E/M code of 99284.

List all the diagnoses addressed during the encounter; focus on chief complaints; list severe or trauma diagnoses first.

Be sure to list “acute chest pain, shortness of breath, etc.” and associated vitals sign abnormalities (e.g., tachycardia, tachypnea, hypoxia) in your diagnoses. Here is an example: A febrile infant required a full septic workup and IV fluids, but the baby is ultimately diagnosed with a URI and viral illness. The diagnoses list should include: Febrile Illness, Dehydration; and URI in that order to fully reflect the work that was done.

Use of macro’s:

When using an electronic medical record, it is common for a physician to use a macro for some portions of the documentation required for a patients visit. Providers should ensure that any information contained in a macro is appropriate for the patient being seen and accurately reflects the work done. Make sure each chart is unique. The EMR should contain patient specific information that is sufficient to support the medical necessity of the service provided. Beware that casual use of macro’s can lead to errors in documentation such as “LMP normal” in a male or “No focal neuro deficit” in a patient seen for chest pain but whose exam reveals extremity weakness from a prior stroke.

Reimbursement and Physician Payment

While in training, residents likely have been exposed to productivity metrics. Residents’ future compensation will be based at least partially on productivity.  The basic element used to measure this productivity is known as the Relative Value Unit (RVU) and it is based on physician effort, training, and other factors.  Each E/M and procedure code is assigned a certain number of RVUs through a specific process.

The Relative Value Update Committee (RUC) is composed of representatives from each specialty and makes recommendations on the value of codes to the Centers for Medicare and Medicaid Services (CMS) for the Medicare Fee Schedule.  Emergency Medicine is represented by ACEP.  The RUC uses the Resource Based Relative Value Scale, or RBRVS, to rank services relative to other services in a budget neutral manner. The RVU has multiple components as illustrated in Figure 1. Physician work captures both the cognitive and procedural work performed by the physician.  The work RVU makes up approximately 72% of the total RVU. The work RVUs are reviewed approximately every five years.  The E/M codes used in Emergency Medicine (99281-99285) were reviewed in 2018 for the 2020 Medicare physician fee schedule. The practice expense RVU is designed to factor in the cost of coding, billing, and collections, as well as the cost of payroll and support staff.  There is also a component that covers liability insurance.

Figure 1. RVU Components

Physician Work + Practice Expense (facility) + Liability Insurance (malpractice) = Total RVU

There is also a Geographic Practice Cost Index (GPCI) that reflects the cost differential in practice based on location.  Each RVU component listed above is adjusted based on the local cost index.  Once the total RVU is determined, it is then multiplied by the Medicare conversion factor (CF), to determine the final payment. For the Medicare conversion factor for physicians is $34.8931/RVU for 2021.

Figure 2. Physician Productivity

Table 4. Current 2019 RVUs for E/M codes 

Code	Description	2021 Work RVUs	2021 Facility PE RVUs	2021 PLI RVUs	2021 Total RVUs
99281	ED visit, level 1	0.48	0.11	0.05	0.64
99282	ED visit, level 2	0.93	0.21	0.10	1.24
99283	ED visit, level 3	1.60	0.33	0.16	2.09
99284	ED visit, level 4	2.74	0.54	0.27	3.55
99285	ED visit, level 5	4.00	0.75	0.43	5.18
99291	Critical Care (30-74 minutes)	4.50	1.42	0.41	6.33
99292	Critical Care additional 30 min increments after initial 75 minutes	2.25	0.72	0.21	3.18

Figure 2. Physician Productivity

RVU/Hour = RVU/patient x Patients/hour

Tips Regarding RVUs

Begin by accurately documenting common Chief Complaints:

The chief complaint good starting point would be to concentrate on some of the most common complaints: abdominal pain, chest pain, shortness of breath, headache, syncope and trauma. Document abnormal vital signs and abnormal diagnostic test results (e.g., elevated creatinine, hyponatremia, hypokalemia) identified during your evaluation.  Many of these workups are complex and can qualify for a level 4 (99284) or level 5 (99285) E/M level of service.

If a level 4 (99284) E/M service is poorly documented and “down coded” to a level 3 (99283), nearly half of the RVU’s are lost.  Residents and new attending physicians often fail to fully document the encounter which results in under coding and lower RVUs.  To ensure proper  documentation and coding, focus on an extended history of present illness, a  complete review of systems, the past medical/ family/ social history, a thorough physical exam, and conclude by documenting a concise and thorough MDM thought process.

The Nature of the Presenting Problem (NOPP) and the complexity of Medical Decision Making (MDM) are the most important factors in determining the appropriate Evaluation & Management (E/M) level of service (LOS). As mentioned previously, the MDM is a key section of the chart in determining the overall code. A succinct summary of the ED treatment that gives context to key labs, EKG’s or imaging studies that were used to develop a patient’s care plan is important. Describing the medical necessity for the workup and treatment that was provided can justify the proper code and document the quality and complexity of the care delivered.

Taking a few extra minutes for this type of documentation can ensure that the physician receives appropriate reimbursement for the work that was performed.

Make sure to do a full procedure note; document site, size, technique, and complexity:

Proper coding for procedures depends on accurate documentation of the procedure performed, indication, location, laterality, complexity, and the technique. Emergency physicians commonly perform orthopedic procedures. If a physician performs procedural sedation, apply a splint, or treat a fracture/dislocation, be sure to document the procedure.

Complete your charts in a timely matter:

Timely completion of documentation will avoid delays in submission of billing.  Late submission can sometimes lead to non-payment of a claim.

Conclusion

This paper is designed to give the graduating resident an overview of the basics of emergency physician reimbursement.  Further information is available through a variety of sources including the ACEP website: ACEP Reimbursement FAQ's. The website has nearly 40Frequently Asked Question sets on emergency medicine coding and reimbursement topics and guidance on compliance and documentation issues.

Updated February 2021