High-level billing in hospital EDs on the rise: How to stay compliant

You may find it beneficial to take a good, hard look at your hospital’s billing practices this year before the government does it for you.

Why? A recent report from the Office of Inspector General (OIG) finds that there’s been an upward trend in high-level billing for evaluation and management (E/M) services provided in emergency departments (EDs) – and it’s looking to figure out why.

Over the past decade, the number of top-level E/M emergency room visits has increased from 27% of Medicare hospital discharges to 48%, according to an article in the New England Journal of Medicine.

The article states that this increase can be attributed to several legitimate trends over the past 10 years, including a push to reduce overcrowding in hospitals.

Because space is at a premium, admitting a patient to the ED only happens after several complex, and often pricey, diagnostic tests are performed to rule out any less serious conditions. Such extensive testing is enough to raise the complexity of medical decision making doctors perform during an ED visit, thus meriting billing for a high-level service.

Due to scarce availability for primary care services, EDs are also seeing an uptick of patients seeking treatment for a variety of issues, some of which aren’t easily identifiable. So doctors end up performing many tests to rule out illnesses. This all adds up to more expensive treatment.

The role of technology

The rise of electronic health records (EHR) systems in hospitals has also contributed to this phenomenon. Hospitals have historically been early adopters for health technology, so this may explain the sharp increases in billing for high-level services in hospital EDs.

While EHRs can be beneficial to revenue generation, enabling doctors to document all services performed on the patient and ensuring the hospital is properly reimbursed, they can also be breeding grounds for errors and fraud if left unchecked.

In that light, it’s important to consistently remind ED physicians of the importance of proper billing. Practices such as checking off boxes for a review of systems that was never performed on a patient, or mindlessly copying and pasting info into patients’ charts can unethically raise billing levels, which may land your hospital in the hot seat.

Support your billing

To protect your hospital, the need for performing complex services on patients must be clearly documented in patients’ medical records. If you have legitimate proof for billing higher-level E/M encounters in the ER, your hospital will be able to effectively defend itself against any scrutiny for its billing practices.

Because ED doctors don’t often bill directly for their services, they may feel disconnected from the billing process. Be sure to let them know that if an audit uncovers any discrepancies, they’ll be just as liable as the hospital is once the feds come knocking, so it’s important they document patient encounters accurately on their end.