Tyler Williams of Payor Logic recently sat down with HFMA to shed light on the key to navigating nonpayment in emergency services billing. Read the full article here.

In recent years, increasingly strict emergency department (ED) requirements from health insurance agencies and the government have resulted in higher rates of payer medical necessity audits and coding denials in emergency medicine. There are three main factors contributing to this issue that healthcare providers need to be aware of—payment cuts to emergency medicine from major payers, incorrect coding of emergency departments claims, and failure to report inappropriate nonpayment activity. This blog breaks down each factor and offers ways for emergency departments to effectively combat billing issues.

Payment Cuts in Emergency Medicine

This year, Humana, Anthem and Medicaid announced new emergency department policies limiting the conditions they will cover and reducing the amount they will pay out. For example, one patient received a $12,000 dollar medical bill after an ED visit for a suspected ruptured appendix was deemed a non-emergency by one of those policies. Many patients may be looking at deductible increases of up to 100 percent—making them the primary payers for their emergency medical expenses rather than their insurance. 

Correct and Comprehensive Coding of ED Claims

Healthcare organizations should make sure coders’ knowledge is up to date to ensure all coding is correct before ED claims are submitted. This is especially true for ICD-10 and Evaluation and Management (E&M) code assignment. Proper use of Modifier 25 is an excellent example of the type of knowledge coders must maintain. Many insurers are proposing a 25 to 50 percent decrease in E&M reimbursement if Modifier 25 is applied. Thus, it is critical for coders to know how and when to use this modifier. 

The key to avoiding coding denials in the ED is to provide accurate documentation and coding within ICD-10. Here are four best practices for ED coding and documentation:

  • Cite a high-quality diagnosis to justify medical decisions
  • Give a specific, detailed final impression—don’t leave any unspecified ICD-10 codes
  • Expand clinical documentation improvement programs into the ED
  • Hire certified coders and billers with experience in ED billing

Reporting Bad Behavior

Rapid response to denials and lower payments and adequate coder training at every level are essential to addressing payment issues. Emergency departments should challenge or appeal any unfair denials with EDPMA and ACEP. Finally, emergency medical centers should take steps that have been shown to address and correct bad payer behavior. The best approach is through a concerted effort among providers, combined with the following proven efforts:

  • Monitor clinical documentation and coding compliance
  • Hire knowledgeable staff
  • Take proactive measures in denial prevention for your organization’s emergency services 

To learn more about how Payor Logic can help your organization combat denials in the emergency department, take a look at our solutions for emergency medicine today.