EDs are billing more high intensity, complex visits

Emergency departments (EDs) bill more frequently at the highest levels of service than they did in prior years. This trend has generated questions as to whether the apparent rise in case severity is due to real changes in patient care needs or “upcoding” – the practice of coding cases at higher levels of complexity without any real change in the level of care performed. Though the term upcoding could connote fraudulent practices, like reporting more work than actually occurred, it may also be a result of legitimate and improved documentation aided by electronic health records.

Researchers recently analyzed Medicare claims data from 2006-2012 to delineate drivers of the increases in high-intensity billing (defined as CPT level 5 E&M 99285 or critical care 99291, 99292) (1). They searched for common features of the high-intensity visits based on visit data, including patient factors (age, race, sex, Medicaid eligibility, comorbidities) and amount of services and procedures performed. Given its use of Medicare data, this study’s results may not be applicable to non-Medicare patients.

Patient factors and increased services accounted for a small to moderate amount of the increase in high-intensity visits. Variation attributable to these variables was 5.1% for inpatient (admissions), 47% for outpatient (discharges), and 15% of all visits. Reclassifying observation visits as admissions did not change these results to a large degree. While up to half of the increase in billing intensity could be explained by the variables examined, more than half of the story still remains unexplained. The remaining portion could have come from upcoding or other factors not measured in this study. Examples of unmeasured factors that might dictate service intensity include clinical data (e.g. vital signs and lab results) and physician time spent.

The drivers of the rise in complex ED visits and the contribution of upcoding remains an open question. It is likely an interplay of changes in clinical practice, the growing role of the ED in treating complex conditions, the increasing complexity of our patient population, as well as more thorough documentation. Understanding the drivers of visit intensity is necessary to assess if the coding system accurately stratifies the evaluation and management of patients by physicians. Policymakers and payers should root out clear cases of fraud but also must recognize that higher intensity visits may represent increased, but unmeasured, real work.

This post first appeared on Policy Prescriptions. This Health Policy Journal Club review is a collaboration between Policy Prescriptions and the Emergency Medicine Residents Association (EMRA). It was written by Angela G. Cai, MD, MBA. She is the EMRA Director of Health Policy and an Emergency Medicine resident at SUNY Downstate/Kings County. Views are solely the author’s and do not represent EMRA.

Reference

Burke LG, Wild RC, Orav EJ, Hsia RY. Are trends in billing for high-intensity emergency care explained by changes in services provided in the emergency department? An observational study among US Medicare beneficiaries. BMJ Open [Internet] 2018;8(1). Available from: https://www.ncbi.nlm.nih.gov/pubmed/29382680