Rising Acuities: The Evolution of Emergency Medicine

Based on a recent flurry of published assertions, emergency department documentation and billing have come into scrutiny as many institutions claim the use of electronic health records has contributed to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill for more complex evaluation and management services.

A recent article in the New York Times titled, "Medicare Bills Rise as Records Turn Electric," stated that "the most aggressive billing — by just 1,700 of the more than 440,000 doctors in the country — cost Medicare as much as $100 million in 2010 alone." 

As a result of the increasing costs for E/M services, the HHS Office of Inspector General has addressed the issue, warning that the coding of evaluation services had been "vulnerable to fraud and abuse." Higher acuities will also be the subject of scrutiny on the part of recovery auditors who will start complex, or chart by chart, reviews of higher levels of service.

While it is conceivable that some providers are upcoding the level of services they provide, I believe the increased costs are a result of the fact EHRs make easier appropriate coding of a growing number of high acuity patients visiting our nation's EDs.

Why the rise in patient acuity?

Much has been made of the perceived rise in the acuity of the patients seen by ED physicians. There are several factors that likely contribute to making this perception a reality.

  • Overwhelmed physicians. Primary care networks and the physician offices that constitute them are increasingly overwhelmed with an influx of patients. The office internist or family physician starts every day with a full schedule, with perhaps one or two slots deliberately left open for same-day appointments for ill patients. But within the spectrum of ill patients, there are many with either more worrisome complaints such as acute shortness of breath, chest or abdominal pain, or those obviously in need of ancillary studies such as acute injury requiring x-ray, that are correctly judged "too sick for the office," and are triaged directly to the emergency department.
  • Medicaid. The Medicaid system is notoriously underequipped to deal with higher acuity patients anywhere but in the ED. Further, the ongoing lack of Medicaid provider resources too often leads to undermanagement of chronic conditions whose recurrent decompensations can then only be managed in the resource-intense environment of the emergency department.
  • The uninsured. For the millions of Americans who remain uninsured, or merely underinsured, care is often not sought until the condition reaches a stage requiring immediate evaluation and management, in which case the ED is most often the only available venue for care. For these patients, emergency departments represent not only their last, best hope but often their only resource, and their self-imposed delay in presentation translates to higher-acuity encounters.
  • Advances in medicine. The evolution and availability of medical care has resulted in dramatic increases in the number of patients with chronic conditions, often with complex treatment regimens. While much of the care of these patients is appropriately handled in the office setting by primary and specialty physicians, treatment of sudden decompensations or complex management quandaries can often only be addressed in the setting of an emergency department.

In sum, today's patient population is older, harbors more medical "success stories" that result in chronic conditions, must navigate a primary care network that is under-resourced, and for the underinsured, often comes to care later and sicker than it should. In all of these circumstances, acuities trend higher, ED physician work is greater and ED pro-fee charges are commensurably higher.

Impact on the ED

Recent studies have demonstrated that the increased intensity of ED services is a substantial contributor to ED crowding, and in many cases may be more important than the often cited (and certainly legitimate) problem of emergency department holding of admitted patients. In a recent study published in the Annals of Emergency Medicine, data was analyzed from annual National Hospital Ambulatory Medical Care Surveys from 2001 to 2008. During the eight-year study period, it was noted that the number of ED visits increased by 1.9 percent per year, a rate 60 percent faster than population growth. Mean occupancy increased even more rapidly, at 3.1 percent per year, or 27 percent  during the eight study years. Among potential factors associated with crowding, the use of advanced imaging increased most, by 140 percent. But advanced imaging had a smaller effect on the occupancy trend than other more common throughput factors, such as the use of intravenous fluids and blood tests, the performance of any clinical procedure and the mention of two or more medications. Of patient characteristics, Medicare payor status and the age group 45 to 64 years accounted for small disproportionate increases in occupancy.[1]

The contribution of the medical malpractice climate

While difficult to accurately quantify in its overall impact on the costs of care, there is general agreement that the practice of "defensive medicine" significantly adds to the increasing price tag of American medicine. ED physicians are particularly susceptible to the perceived need to maximally work up many complaints. All patients in the ED are, by definition, "new" patients to the examiner and therefore have no loyalty or personal relationship with the ED physician. With every encounter, physicians must consider the worst scenarios with respect to the patient's condition. Not surprisingly, over testing is not uncommon in the specialty and materially contributes to increasing the complexity of the encounter, with resultant higher level coding.

The availability of CT and MRI scanning, bedside ultrasound and same day stress-testing for ambiguous chest pain are examples of the type of ancillary testing that, while improving diagnosis and treatment, is often performed because it is available  — and due to concerns about litigation if it is not performed. Primary care physicians who send their patients to the ED often do so because of the availability of an in-depth workup, and specialists often mandate extensive workup and testing by an emergency physician before they will consult on a patient. Additionally, patients themselves have ratcheted up the ante based on their own improved medical sophistication and desire for more extensive testing.

Thus, emergency physicians are simply doing more than they used to, and not always for the right reasons. The net impact is an increase in emergency physician charges that correlates to an increase in perceived (and coded) patient acuity.

The relative perceived increase in acuities due to improved documentation

There has been a substantial positive evolution of the quality of medical records over the last two decades. The 1995 Medicare Documentation Guidelines provided hard-line standards for requisite element counting to determine compliant coding of E/M services. These E/M services account for 85 percent of emergency physician revenue, on average.

After 1995 DGs were released, many EDs began to use templates — either home grown or commercialized options — to document E/M services. The templates feature checkboxes and "fill in the blanks" to account for the necessity of meeting the documentation requirements for charting ED encounters. Prior to the advent of the 1995 DGs, most emergency department records were handwritten on a blank sheet, and this continued to be the case in many hospitals for a number of years. Even with the use templates, many physician practices continued to consistently under-document their more complex encounters resulting, with compliant coding, in an apparent lower overall patient acuity mix than was actually being seen. This scenario was especially prevalent in practices in which physicians were hospital employees, where the ED was often seen as a loss leader and little attention was paid to the emergency department revenue cycle. In other words, it is quite possible for an emergency department practice to leave a considerable amount of collections on the table annually due to documentation deficiencies.

In the past several years, electronic health records have proliferated, and thanks to federal meaningful use reimbursements, are becoming virtually universal. These systems provide not only an electronic template, but progressively lead the physician through the requisite documentation steps to achieve higher level billing. In some cases, the EHR offers real-time feedback to the physician, predicting the actual E/M level currently documented, and in worst case scenarios, making suggestions of how the documentation might be enhanced. For example, it might prompt a physician with, "Only 9 review of systems provided. Level 5 requires 10." This sort of prompting, while reminding the physician of higher-level documentation requirements, also carries the risk of actively coercing the inclusion of some elements that may not have been routinely performed, or in a truly bad case scenario, may not have been performed at all.

One such scenario can be referenced in the aforementioned New York Times article, which presents an instance of overbilling from a healthcare consultant who came to the emergency room of a Virginia hospital with a kidney stone. After receiving the bill, he noticed a complete physical exam that never happened on his electronic medical record, which meant the visit was billed at the highest level. The patient went on to say that "no one would admit it, but the most logical explanation was that the doctor went to a menu and clicked standard exam, and the software filled in an examination of all of his systems," even though the lower part of his body was never examined by the physician. This illustrates an example of how meaningful use requirements, paired with EHR software technology — and not the physicians themselves — are responsible for the recent spike in intensity of services and higher coding. The net impact is that it has become much easier to capture all documentation elements required for higher level billing.

Additionally, the very circumstance of converting to an EHR causes physician practices to look at documentation requirements, often for the first time, with a resultant improvement in the assiduousness with which they document. Thus, services that might previously have been undervalued and underreported due to documentation deficiencies may now meet the compliant coding requirements of higher-acuity encounters. There is absolutely no doubt that if CMS compares current acuities to those of ten years ago, a substantive contributor to the apparent increase in patient acuities resulting in higher-level coding is simply due to the fact that poor documentation resulted in historical undercoding of many cases.

Detail and integrity key to conquering the increase

In order to reduce compliance risk and optimize the collections they receive from encounters, emergency medicine physicians can seek out experts to compliantly code the records they submit. It is critical to work with organizations that provide coding quality assurance and implement coder education that gives added emphasis to the pitfalls of overcoding in an effort to abate coding errors that will not affect revenue. Educational endeavors on the part of emergency physicians should focus on the target rich audit environment of emergency medicine, and its implications for thorough, accurate and truthful reporting.

Finally, it is critical to advocate with emergency medicine industry groups such as the American College of Emergency Physicians and the Emergency Department Practice Management Association. Working with CMS and private insurers to enhance understanding of the realities of modern emergency medicine practice and the impact of the factors noted above on increasing patient acuity will improve all areas of business in any emergency department practice.

In sum, in the practice of emergency medicine over the past two decades there has been an increase in the intensity of applied services, a rise in patient acuities due both to the success of modern medicine and the increased reliance on emergency medicine as the safety net for shortfalls elsewhere in the healthcare system, a litigious climate that leads to cautious overutilization of ED resources and an electronic record environment that both encourages and rewards more detailed documentation. The net impact is a significant rise in coding levels, billing, and, as a result, increasing scrutiny by payors who, seeing only the bottom line, will continue to question whether their money is being properly spent.

Footnotes:
[1] Stephen R. Pitts, Jesse M. Pines, Michael T. Handrigan, Arthur L. Kellermann (22 June, 2012) Annals of Emergency Medicine - “National Trends in Emergency Department Occupancy, 2001 to 2008: Effect of Inpatient Admissions Versus Emergency Department Practice Intensity”

Ronald W. Stunz, MD, FACEP, is the medical director of MMP. He delivers documentation in-service sessions with ED physicians and has been with MMP for more than seven years after a 25-year career as a practicing physician. Dr. Stunz has served in a number of hospital administrative capacities, including chairman of the Department of Medicine for Bryn Mawr Hospital and chairman of the Department of Emergency Medicine for Main Line Health. He is the co-chair of PaACEP's Reimbursement Committee; chapter representative to the Highmark Contractor Advisory Committee; member of the Government Affairs Committee, and co-organizer of the 2010 Chapter Reimbursement Conference. Additionally, he has also served as a Delegate to the National ACEP Council. Dr. Stunz serves on EDPMA task forces on healthcare reform, quality initiatives and documentation guidelines. He has been board certified by the American Boards of is board certified in Internal Medicine and Emergency Medicine, and is a graduate of Case Western Reserve University and the Université de Reims, France.

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