What Every Graduating Resident Needs To Know About Reimbursement

Introduction

As a resident, you spend many years primarily focused on learning to provide excellent patient care.  You may have had some exposure to billing and payment issues during your training, but these experiences are often varied if they exist at all.  This paper covers the basics of emergency medicine reimbursement and is designed to prepare you to enter practice.   For simplicity, the information has been broken down into the subheadings of Coding and Documentation, as well as Reimbursement and Physician Payment.

 

Coding and Documentation

When you generate a chart for a patient encounter, this information is used by coders to assign specific codes.  It is important to be clear in your documentation, as these coders do not make inferences about the care provided.  Similarly, the codes that they generate are the codes used by payers to determine payment – and they see no 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 is hefty, in emergency medicine we have 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 your documentation leads to a choice of a specific code by the coder.  The left-hand column of the Table 1 lists the codes commonly used for emergency medicine encounters.  There are also additional codes of note: for example, 99291 is for critical care. There are also codes for observation services and for specific procedures, which will not be discussed, in this basic overview. 

 

Table 1. E/M Codes and the extent of service required

E/M Code

History

Exam

MDM

99281

Problem-focused

Problem-focused

Straightforward

99282

Expanded

Expanded

Low Complexity

99283

Expanded

Expanded

Moderate Complexity

99284

Detailed

Detailed

Moderate Complexity

99285

Comprehensive

Comprehensive

High Complexity

 

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

 

Table 2. Definitions of the extent of service for Historical and Physical Exam elements.

Extent of Service

History

Physical Exam

Problem focused

CC, brief HPI

Limited exam of affected part

Expanded

 CC, brief HPI

+ Problem pertinent system review

 Limited exam of affected part

+ Other symptomatic or related organ system or body areas

Detailed

Extended HPI

+ Extend review of systems

+ Pertinent past, family, and/or social history

Extended exam of the above (5 to 7)

Comprehensive

Extended HPI

+ Complete review of systems

+ Complete past, family, and social history

General multisystem exam OR complete exam of a single organ system (8 or more)

 

It is important to note that your Medical Decision Making, or MDM, is the element of the chart that will likely set the highest possible code and communicate to your coders the complexity of the patient encounter.  The complexity is determined by three elements: the number of diagnoses and management options that must be considered; the data and testing reviewed; and the potential risk of complications, morbidity 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/None

Minimal

Low Complexity

Limited

Limited

Low

Moderate Complexity

Multiple

Moderate

Moderate

High Complexity

Extensive

Extensive

High

 

But what about ICD Diagnosis Codes?

 

During your training, you have likely heard about ICD codes – so what are these, and how do they relate to the CPT codes that we just discussed?

 

The International Classification of Diseases, or ICD, 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 what services they will pay for.  For example, some private payers will not pay above a 99283 for a diagnosis of gastroenteritis.  This can lead into a very complex discussion of negotiated rates for services, which is beyond the scope of this paper.  However, it also raises the point that it is important not only to fully capture the work that you have done in your chart, but also to thoughtfully list your diagnoses as well.

 

Tips for Documentation

 

Don’t get down coded – ensure that all chart elements are satisfied for the level of the encounter. 

Example: A 99285-eligible encounter requires a comprehensive history, so if you don’t do a complete past, family, and social history your chart would be down coded to a lower level of service than it might otherwise have merited. If you only record pertinent portions of those elements, your documentation would only be able to support an E/M code of 99284. However, if you miss all of those portions of the history, your chart would only support an E/M code of 99283.

 

Thoughtfully list your diagnoses – focus on chief complaints; list severe or trauma diagnoses first.

You worked up chest pain, so why only get paid for GERD?

Here is another example: A febrile infant required a full septic workup and IV fluids, but the baby is ultimately diagnosed with a URI – the diagnoses should be listed with febrile illness first, next dehydration, and URI last to fully reflect the work that was done.

 

Reimbursement and Physician Payment

 

While in training, you may have been exposed to productivity metrics. Chances are your future compensation will be based at least partially, if not fully, on your productivity.  The basic element used to measure this productivity is known as the RVU, or the Relative Value Unit – 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 RBRVS, or Resource Based Relative Value Scale, to rank services relative to other services (for example, 45 minutes of a primary care visit versus 45 minutes of thoracic surgery) in a budget neutral manner.  The RVU has multiple components, as illustrated by the figure below.  Physician work captures both the cognitive and procedural work performed by the physician.  The work RVU makes up approximately 72% of the total RVU. These are reviewed every five years.  The E/M codes will be reviewed in 2017.  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 something call the GCPI, or the Geographic Practice Cost Index, which reflects the cost differential in practice based on location.  Each RVU component listed above is adjusted based on this local cost index.  Once the total RVU is determined, it is then multiplied by the conversion factor (CF), which is set each year by CMS.

 

Table 4. Current 2016RVUs for E/M codes

 

Code

Description

2016 Work RVUs

2016 Facility PE RVUs

2016 PLI RVUs

2016 Total RVUs

99281

ED visit, level 1

0.45

0.11

0.04

0.60

99282

ED visit, level 2

0.88

0.21

0.08

1.17

99283

ED visit, level 3

1.34

0.29

0.12

1.75

99284

ED visit, level 4

2.56

0.53

0.23

3.32

99285

ED visit, level 5

3.80

0.75

0.35

4.90

99291

Critical Care

1st hour

4.50

1.42

0.39

6.31

99292

Critical Care additional 30 min

2.25

0.72

0.19

3.16

 

Figure 2. Physician Productivity

 

RVU/Hour = RVU/patient x Patients/hour

 

Tips for Generating RVUs

 

Begin by accurately documenting common Chief Complaints: a 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. Many of these workups are complex and 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 simply fail to fully document the encounter – resulting in under coding and lower RVUs.  To improve, focus on an extended history of present illness, a more complete review of systems, the past medical/ family/ social history, a thorough physical exam, and wrap it up by documenting a better MDM thought process. Taking a few extra minutes can ensure you get paid for the work you actually did and was indicated based on the presenting Chief Complaint. . By better documenting just a few charts on every shift, a physician can significantly increase his the total RVU production.

 

Conversely, don’t waste time and effort over-documenting simple, straight-forward medical issues.

 

Make sure to do a full procedure note – site, size, technique, complexity.

Proper coding for procedures depends on accurate documentation of location, laterality, complexity, and technique.

 

Recognize that this is a balancing act

Increasing RVU’s per patient – want to be sure to get the maximum amount per encounter

Increasing patients per hour – work to efficiently see an increased number and variety of patients

Example: Start an extensive workup on chest pain patient (perhaps a 99285 visit). While that is in process, see a toddler with a nursemaid’s elbow who requires a reduction.

 

Complete your charts in a timely matter

Your group will care about days to submission of a bill, and you do not want to be the cause of any delay.

 

Conclusion

 

This paper is designed to give you an overview of the basics of emergency physician reimbursement.  It admittedly only scratches the surface of a very interesting and complex topic.  Further information is available through a variety of sources – with a good starting point being www.acep.org/reimbursement/. This website has significant content including nearly forty FAQ sets on emergency medicine coding and reimbursement topics and guidance on compliance and documentation issues.

 

Updated 3/2/2016

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