Emergency medicine coding compliance example


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Patient	Date of Service	Payor	ABC Coding 00(PRO)00	TCN's Coding 00(PRO)00	00Comments00	Variance	ABC Coding (FACILITY)	TCN's Coding (FACILITY)	00Comments00	Variance
1	1/1/03	SP	99282	99283	Med given	X	99282	99283	Med given	X
2	1/1/03	COMM	99282	99283	Rx, X-Ray	X	99282	99283	Rx, X-Ray	X
3	1/1/03	COMM	99282	99282			NO CODE	99283	Med given, missed E&M level	X
4	1/1/03	COMM	99283	99284	MDM moderate, detailed exam	X	99284 90784X2	99285-25 90780 90784 94760	Labs, IV start, injection X1, ultrasound	X
5	1/1/03	BCBS	99283	99284	X-Ray, lab, IV Narc	X	99283	99285-25 90784X4 51701	CT, IV injections, cath	X
6	1/1/03	SP	12011	99283-25 12011	Missed EM level	X	99283 12011	99283-25 12011 90471 90718	TD given	X
7	1/1/03	SP	99283	99283			99283	99283-25 90782	Injection given	X
8	1/1/03	SP	99284	99284 93010	EKG interpreted	X	99384 93005	99285-25 36000 90782 93005 94760	EKG, X-Ray, labs	X
9	1/1/03	M/CARE	99285	99284	Inadequate ROS, no CC time	X	99285-25 90784 93005	99291-25 Q0081 90784X2 93005 94760	MI, heparin	X
10	1/1/03	M/CAID	99281	99283	Back pain, Rx given	X	99282	99283	Rx given	X
11	1/1/03	BCBS	99281	99281			99281	99282		X
12	1/1/03	M/CAID	99283	99284	ABD pain, labs, ultrasound	X	99283	99284-25 90782	IM injection	X
13	1/1/03	TRICARE	99283	99283-25 25622-54	FX care	X	99282	99283-25 25622	X-Ray, Rx	X
14	1/1/03	COMM	99283	99283			99282 90782	99283-25 90471 90718	TD given	X

Findings

Coding Protocol

The Coding Network adheres to the American College of Emergency Physicians’ coding policies, as well as, CPT and ICD-9 coding principles. The Coding Network also codes according to payor specific guidelines, recognizing that some payors bundle services while others do not. This is particularly true of Medicaid and Medicare carriers. Additionally, The Coding Network recognizes that professional services coding and facility services coding have distinct documentation requirements. These distinct requirements can result in different E&M levels of service being assigned on the professional versus the facility side for the same patient encounter.

Sample Size

The hospital provided 357 emergency medicine charts to review for the accuracy of the professional fee coding. The Coding Network compared 314 charts. 43 charts could not be compared for the following reasons: 9 charts represented patients that left without being seen.
• 2 charts were coded by ABC’s coders with two E&M levels of service for the same date of service.
• 27 charts were not assigned E&M levels of service by ABC’s coder(s).
• 3 charts represented patients who were treated by their primary physicians.
• 1 chart did not have a physical exam documented and was therefore not codeable.
• 1 chart was missing the T-sheet.

Average Patient Charge (APC) / Fee Schedule

Typical professional fee average patient charges run between $225 - $275 nationwide. ABC Hospital’s fee schedule and distribution yielded a $114.71 average patient charge while The Coding Network’s coding yielded an average patient charge of $166.84. There is a $52.13 or 10.2% variance between the ABC’s APC and The Coding Network APC.
The fees for 99281-99285 and 99291 appear to be below market averages. We suggest that the hospital review these fees and make adjustments.

Coding Errors

Out of 314 charts that both ABC’s and The Coding Network coded, 193 or 61% of the charts coded for level of service by the ABC’s were incorrect. From the 314 chart sample, coding errors on levels of service are described below by financial class:
Medicaid 1 Chart downcoded from Level 5 to Level 4 1 Chart downcoded from Level 5 to Level 3 10 Charts downcoded from Level 4 to Level 3 30 Charts downcoded from Level 3 to Level 2 2 Charts downcoded from Level 3 to Level 1 2 Charts downcoded from Level 2 to Level 1 46 Coding errors out of 73 charts (63% error rate) Blue Cross/Blue Shield 1 Chart downcoded from Critical Care to Level 5 1 Chart downcoded from Level 5 to Level 4 1 Chart downcoded from Level 5 to Level 3 10 Charts downcoded from Level 4 to Level 3 1 Chart downcoded from Level 4 to Level 2 13 Charts downcoded from Level 3 to Level 2 2 Charts downcoded from Level 3 to Level 1 1 Chart upcoded from Level 3 to Level 4 30 Coding errors out of 52 charts (58% error rate) Tricare 1 Chart downcoded from Level 3 to Level 2 1 Coding errors out of 2 charts (50% error rate) Workers’ Comp 1 Chart downcoded from Level 4 to Level 3 1 Chart downcoded from Level 4 to Level 2 3 Charts downcoded from Level 3 to Level 2 1 Chart downcoded from Level 3 to Level 1 6 Coding errors out of 9 charts (67% error rate)	Medicare 1 Chart downcoded from Level 5 to Level 4 2 Charts downcoded from Level 5 to Level 3 11 Charts downcoded from Level 4 to Level 3 2 Charts downcoded from Level 4 to Level 2 19 Charts downcoded from Level 3 to Level 2 1 Chart downcoded from Level 3 to Level 1 1 Chart upcoded from Level 4 to Level 5 37 Coding errors out of 62 charts (60% error rate) Commercial 1 Chart downcoded from Level 5 to Level 4 1 Chart downcoded from Level 5 to Level 3 8 Charts downcoded from Level 4 to Level 3 2 Charts downcoded from Level 4 to Level 2 24 Charts downcoded from Level 3 to Level 2 3 Charts downcoded from Level 3 to Level 1 2 Charts upcoded from Level 2 to Level 3 41 Coding errors out of 65 charts (63% error rate) VA 1 Chart downcoded from Level 3 to Level 2 1 Coding errors out of 1 chart (100% error rate) Self Pay 1 Chart downcoded from Level 5 to Level 4 1 Chart downcoded from Level 5 to Level 3 5 Charts downcoded from Level 4 to Level 3 1 Chart downcoded from Level 4 to Level 2 20 Charts downcoded from Level 3 to Level 2 3 Charts downcoded from Level 3 to Level 1 31 Coding errors out of 50 charts (62% error rate)
Grand Total: 193 Errors out of 314 charts (61% error rate) • 189 charts downcoded • 4 charts upcoded
The 27 charts that were not coded by ABC Hospital with an E&M level of service would have been coded by The Coding Network as follows: 99284 1 chart 99283 18 charts 99282 6 charts 99281 2 charts Additionally, the following ancillary procedure coding errors were made:
Procedures Not Documented Sufficiently for Billing Purposes 1 12001 Not documented sufficiently for billing purposes 1 16000 Not documented sufficiently for billing purposes 1 29130 Not documented sufficiently for billing purposes 1 29515 Not documented sufficiently for billing purposes 3 93010 Not documented sufficiently for billing purposes 7 Procedures not documented sufficiently for billing purposes Missed procedures 2 21800 Fracture care, rib 2 25600 Fracture care, distal radius 1 25622 Fracture care, carpal scaphoid 2 26600 Fracture care, metacarpal 1 27520 Fracture care, patella 1 27786 Fracture care, distal fibula 1 27808 Fracture care, bimalleolar ankle 1 28470 Fracture care, metatarsal 1 29515 Application short leg splint 1 64400 Nerve block, trigeminal 1 92977 Thrombolysis, IV infusion 3 93010 EKG, interp and report only 17 Missed procedures	Procedures coded incorrectly 1 12002 Should have been 12032 2 12011 Should have been 12051 1 20103 Should have been 12001 1 29125 Should have been 25600 1 31238 Should have been 30901 1 92950 Should have been 99285 7 Procedures coded incorrectly The following modifiers were missed by ABC coders 34 -25 Significant separately identifiable E&M on same day as procedure 12 -54 Surgical care only
These additional 31 ancillary procedure coding errors equal an additional 10% error ratio. With the 193 E&M level of service errors and 31 ancillary procedure errors added equal 224 or an overall error rate of 71%. It should be noted that while the 189 downcoded charts and 17 missed procedures depress potential income, the 4 upcoded charts, 14 incorrectly coded procedures, and 46 missed modifiers represent a compliance risk for the practice. The following nine professional fee codes were not on the charge master 3 25600 Fracture care, distal radius 1 25622 Fracture care, carpal scaphoid 2 26600 Fracture care, metacarpal 1 26720 Fracture care, phalangeal shaft 1 27520 Fracture care, patella 1 27786 Fracture care, distal fibula 1 28470 Fracture care, metatarsal 1 92977 Thrombolysis, IV infusion 1 93010 EKG, interp and report only 19 Occurrences of codes not on charge master

Coding Comparison

Code ABC Hospital The Coding Network Variance

99281 17 3 -14

99282 139 25 -114

99283 130 200 +70

99284 23 71 +48

99285 5 14 +9

99291 0 1 +1

Grand Total 314 314

Procedures 40* 49 +9

*14 errors: 8 procedures coded incorrectly and 6 procedures not documented sufficiently

Dollar Comparison

314 Sample Visits / 32,200 Total Visits

Fee Schedule Variance

ABC Hospital
Total Charges The Coding Network
Total Charges

$36,018.08
(APC = $114.71) $52,387.71
(APC = $166.84)

APC = Average Patient Charge

$166.84 TCN APC - $114.71 ABC APC = $52.13 APC Variance (45.4%)

Annualization of Charges and Collections

ABC Hospital

$114.71 ABC APC x 32,200 Annual Visits = $3,693,662 Annual Charges
$3,693,662 Annual Charges x 55% Collection Ratio = $2,031,514 Annual Collections

The Coding Network

$166.84 TCN APC x 32,200 Annual Visits = $5,372,248 Annual Charges
$5,372,248 Annual Charges x 55% Collection Ratio = $2,954,736 Annual Collections

Data provided by ABC Hospital

• 55% Collection Ratio
• Total Visits: 32,200

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