Emergency Department Coding Audit

May 30, 2008

Xxxxxx Xxxxxxxxx

Director of Revenue and Compliance

Department of Emergency Medicine

11111 South Xxxxxxx Boulevard

Xxxxxxxxx, XX 111111

RE: Coding Review of 104 Emergency Department Charts

Dear Mr. Xxxx,

Thank you for retaining The Coding Network to review the facility and professional services documentation and coding accuracy of a sample of 104 Emergency Department charts. I have enclosed a patient-by-patient coding spreadsheet that compares XXXX’s original coding with The Coding Network’s proposed coding. Variances in the coding are explained in the comments columns. Additionally, I have enclosed tables that summarize the distribution of the evaluation and management services coding and ancillary procedure coding performed by both sets of coders, as well as, an analysis of both the facility and professional services coding.

The salient findings from the study are as follows:

Facility Services Coding:

1. There was a variance in the E&M level of service coding of 22 charts out of 104 charts or 21%.

• 16 charts of the 104 charts were overvalued according to the ACEP Facility Coding Protocol or 15%.
• 6 of the 104 charts were undervalued according to the ACEP Facility Coding Protocol or 6%.
• Note: It was our understanding that the facility services E&M codes were duplicates of the professional services E&M codes. There were 3 charts where the facility services codes were one E&M level lower than their professional services counterparts.
• 206 were missed (documented but not coded):
  • 179 of the 206 missed were hydration, injection and infusion services;
• 2 procedures were coded but not adequately supported by the documentation and;
• 2 procedure codes were assigned for services not recognized by OPPS.

1. The Average Patient Charge for the XXXX coders was $1,478. The ACEP coding protocol produced an APC of $1,848. This is a variance of $370 per patient or 25%.
2. 210 ancillary procedure coding variances were identified:

1. Total coding variances:

 22 Level of service coding variance

210 Ancillary procedures coding variance

232 Total coding variances in the 104 charts considered

1. Documentation: Overall, the documentation by the nursing staff was good. The order form was comprehensive and the nursing record had appropriate grids for recording the necessary information and was well utilized. There were several instances where no stop time was documented for hydration services and therefore no CPT code could be assigned for that service.
2. Facility Coding Protocol: It is our understanding that the current facility coding protocol is to follow the professional services coding for the E&M level of service. This is in direct contradiction to the expectations expressed in the Federal Register which recommend that the focus be on the intensity and level of hospital resources brought to bear on the patient care rather than the physician resources. We recommend that the hospital consider using the ACEP facility coding protocol with whatever modifications are appropriate to this specific environment.

Professional Services Coding:

1. There was a variance in the E&M level of service coding of 14 charts out of 104 charts or 13%.

• 3 of the 104 charts were overvalued by XXXX coders or 3%. This type of error represents limited third party audit exposure or possible recoupment.
• 11 of the 104 charts were undervalued by XXXX coders or 11% resulting in lost income opportunities.
• 16 procedures were coded but not adequately supported by the documentation;
• 2 procedure codes were missed and;
• 1 procedure code was assigned an incorrect code.

1. The Average Patient Charge for the XXXX coders was $1,119. The Coding Network’s coding produced an APC of $1,142. This is a variance of $23 per chart or 2%.
2. 19 ancillary procedure coding variances were identified:

1. Total coding variances:

14 E&M Level of service coding variances

19 Ancillary procedure coding variances

33 Total coding variances out of 151 CPT codes considered (104 charts) or 22%

1. Modifier Usage: The following modifier variances were noted but not counted as errors.

• There was one instance where modifier -54 was applied to a splinting procedure.
• There were 15 instances where modifier –GC (Medicare modifier indicating Resident involved in care) should have been applied. The report from which we obtained the original coding did not include this modifier.

1. 6. Physician Documentation Deficiencies:

• E&M Services: There were 2 instances where inadequate History of Present Illness (HPI) documentation caused The Coding Network’s coders to downcode the E&M level of service from 99285 to 99283.
• Rhythm ECG Interpretations: In 2008, the CPT definition concerning the documentation requirements for Rhythm ECG interpretations was modified. There were 14 instances where no order was documented for the cardiac monitor thereby creating a deficiency which prevented The Coding Network’s coders from assigning code 93042.
• Ultrasound: There were 2 instances where the documentation was incomplete regarding ultrasound interpretations. The documentation must include 1) a statement that the ultrasound was performed bedside and 2) an interpretation of the ultrasound by the ED physician.
• Attestation: All Attestations stated "discussed with resident," even in those cases when a midlevel provider managed the patient care. We recommend that the attestation be specific as to whether discussed with “resident” or “midlevel provider.”

The Coding Network offers a variety of programs designed to support hospital coding and physician and nursing documentation skills which include:

• Quarterly, semi-annual or annual coding reviews
• Outsourced Emergency Department facility and professional services coding
• Emergency physician and nurse documentation training programs

You can reach me at (310) 459-4186 or via email at ngreen@codingnetwork.com with any questions.

All of us at The Coding Network appreciate this opportunity to assist the XXXX Department of Emergency Medicine to improve its coding.

Sincerely,

Neal Green

Neal Green, M.B.A.

Executive Vice President

Encl.

 

 

FACILITY CODING ANALYSIS

1. I. FINDINGS:

Coding Protocol

It is our understanding that the current facility coding protocol is to follow the professional services coding for the E&M level of service. This is in direct contradiction to the expectations expressed in the Federal Register which recommend that the focus be on the intensity and level of hospital resources brought to bear on the patient care rather than the physician resources (see items 1 and 2 below). Per the Federal Register, the general expectation and requirements for hospitals’ individual coding guidelines are as follows:

(1) The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code (65 FR 18451).
(2) The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources (67 FR 66792).
(3) The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits (67 FR 66792).
(4) The coding guidelines should meet the HIPAA requirements (67 FR 66792).
(5) The coding guidelines should only require documentation that is clinically necessary for patient care (67 FR 66792).
(6) The coding guidelines should not facilitate upcoding or gaming.
(7) The coding guidelines should be written.
(8) The coding guidelines should be applied consistently across patients in the
clinic or emergency department to which they apply.
(9) The coding guidelines should not change with great frequency.
(10) The coding guidelines should be readily available for fiscal intermediary (or, if applicable, MAC) review.
(11) The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.

The Coding Network utilized the American College of Emergency Physicians’ (ACEP) acuity based criteria for Emergency Department facility level coding and compared those results to XXXX’s original coding. The ACEP protocol is simple to use and typically yields a more favorable revenue stream than most hospital coding protocols. We recommend that the hospital consider using the ACEP facility coding protocol with whatever modifications are appropriate to their specific environment.

Sample Size / Source of Original Coding

XXXX provided 104 Emergency Department charts to review. The original coding was provided via an Account Detail Data document which listed the descriptors of the services billed along with the CDM code which could be crosswalked to a CPT code.

Average Patient Charge

XXXX’s coding produced an Average Patient Charge of $1,478. The ACEP coding protocol produced an APC of $1,848. This is a variance of $370 per patient or 25%.

Coding

The coding variances in the E&M level of service assignment were as follows:

Overvalued:
# Charts	XXXX Coded	TCN Coded
1	99291	99285
12	99285	99284
2	99284	99283
1	99283	99282
16 Variances out of 104 charts coded (21% variance rate)
Undervalued:
# Charts	XXXX Coded	TCN Coded
2	99285	99291
2	99284	99285
2	99283	99284
6 Variances out of1045 charts coded (6% variance rate)
Total: 22 Variances out of 104 charts coded (21% variance rate)

Ancillary procedural coding variances were as follows:

Hydration and Therapeutic Injections and Infusions

The most significant coding issue for the ancillary services was the fact that hydration, therapeutic injections and infusions were not coded at all by XXXX. This negatively impacted the coding outcomes of 57 of the 104 charts and resulted in $33,776 in lost charges.

We identified the following 179 missed hydration, infusion, or injection services:

#	CPT	Description	Chart #s
2	90471	Immunization Admin	3,7
2	90718	Tetanus & diphtheria toxoids	3,7
5	90760	IV Infusion, Hydration, up to 1 hr	2,14,24,54,63
32	90761	IV Infusion, Hydration, each add’l hr	12(x3),13(x2),21(x5),32(x2),42,44,46,55,63(x2),65,71,77,78,88(x2),90(x2),92(x2), 95(x3),104
8	90765	IV Infusion, Therapeutic, initial	1,21,44,45,69,77(x2),91
1	90766	IV Infusion, Therapeutic, each add’l hr	43
6	90767	IV Infusion, Therapeutic, add’l sequential	45(x6)
5	90772	Injection, Therapeutic, IM, SQ	35(x2),45,50,93

 

#	CPT	Description	Chart #s
38	90774	IVP, initial	4,7,9,11,12,13,17,25,27,28, 29,32,34,37,42,43,46,47,48, 55,56,64,65,71,72,74,76,78, 84,88,90,92,95,96,97,101, 103,104
42	90775	IVP, each add’l	1,4,9,11,12(x2),17(x2),21,27,28(x2),34,37,43(x2),44(x2), 45(x2),47,48,55,64,65,69(x3),71,74(x2),76(x2),78(x2),84,88(x2),95,96,103(x2)
38	90776	IVP, each add’l sequential	1,4,9,11(x2),12(x3),17,21,27(x2),28,34,42(x2),45(x5),47,48,71(x4),74(x2),76,90, 96(x2),101(x2),103(x3)
Total: 179 Missed hydration/infusion/injection services

The following 27 other ancillary procedures were appropriately documented in the medical record but not coded (missed):

#	CPT	Description	Chart #s
1	51700	Bladder irrigation	88
1	51701	Non-indwelling bladder cath insertion	79
2	51702	Foley cath insertion	69,76
17	93005	EKG	8,14,21,27,29,34,39,43,49, 52,54,76,90,91,93,98,104
1	93041	Rhythm strip	65
1	94760	Pulse oximetry, single	91
4	94761	Pulse oximetry, multiple	39,57,65,79
Total: 27 Missed ancillary procedures

The following 2 procedures were coded but not adequately supported by the documentation:

Chart #	XXXX Coded	Description
43	76880-TC	No documentation that ultrasound performed at bedside.
58	94761	Pulse oximetry not medically necessary
Total: 2 procedures not supported by documentation

The following 2 CPT codes are not recognized by OPPS. Typically, other ancillary services that are required for sedation are billed in lieu of actual sedation codes, i.e, cardiac monitor, pulse oximetry, infusions or injections:

Chart #	XXXX Coded	Description
57	99149	Moderate Sedation
65	99144	Moderate Sedation
Total: 2 procedures not recognized by OPPS

Total coding variances:

 22 Level of service coding variance

210 Ancillary procedures coding variance

232 Total coding variances in the 104 charts considered

Documentation Deficiencies

1. Overall, the documentation by the nursing staff was good. The order form was comprehensive and the nursing record had appropriate grids for recording the necessary information and was well utilized. There were several instances where no stop time was documented for hydration services and therefore no CPT code could be assigned for that service.
   1. II. Coding Comparison

104 Chart Sample

The Coding

Code XXXX Network Variance

99281 0 0 0

99282 1 2 -1

99283 7 6 +1

99284 41 51 -10

99285 52 41 +11

99291 3 4 -1

Grand Total: 104 104

Procedures 85 289 204

 

1. III. DOLLAR COMPARISON

104 Chart Sample / 38,925 Total Visits

A. Variance Calculation

XXXX The Coding Network

Total Charges Total Charges

$153,718 $192,221

(Average Patient Charge = $1,478) (Average Patient Charge = $1,848)

Sample Variance = $38,503

$1,848 TCN APC - $1,478 XXXX APC = $370 APC Variance (25%)

B. Sample Size Extrapolation to Annual Additional Charges and Collections

1. Projected Annualized Charges and Collections (XXXX APC)

$1,478 XXXX APC x 38,925 Annual Visits* = $57,531,150 Annual Charges

$57,531,150 Annual Charges x 30% Collection Ratio* = $17,259,345 Annual Collections

2. Projected Annualized Charges and Collections (The Coding Network APC)

$1,848 TCN APC x 38,925 Annual Visits* = $71,933,400 Annual Charges

$71,933,400 Annual Charges x 30% Collection Ratio* = $21,580,020 Annual Collections

C. Net Collection Variance

$21,580,020 TCN Projected Annual Collections (ACEP Protocol)

- $17,259,345 XXXX Projected Annual Collections

$4,320,675 Projected Additional Annual Collections (25% increase)

*Annual visits and Collection Ratio provided by Xxxxx Xxxxxxxxx.

 

 

PROFESSIONAL SERVICES CODING ANALYSIS

1. I. FINDINGS:

Coding Protocol

A. 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

B. XXXX provided 104 charts to review. The original coding was provided via either an Account Detail Data document or a View Invoice Detail Group 3 document which listed the descriptors of the services billed along with the CDM code which could be crosswalked to a CPT code.

Average Patient Charge

C. XXXX’s coding produced an APC of $1,119 while The Coding Network’s coding produced an APC of $1,142. This represents a variance of $23 per chart or 2%.

Coding

D. Coding variances on E&M levels of service are described below:

Overvalued:
# Charts	XXXX Coded	TCN Coded
1	99285	99284
1	99285	99283
1	99284	99283
3 Variances out of 104 charts coded (3% variance rate)
Undervalued:
# Charts	XXXX Coded	TCN Coded
9	99284	99285
2	99283	99284
11 Variances out of 104 charts coded (11% variance rate)
Grand Total: 14 Variances out of 104 charts coded (13% variance rate)

 

Coding variances on ancillary procedure coding are described below:

16 procedures were coded but not supported by the chart documentation:

Chart #	XXXX Coded	Description
1,6,8,11,14,31,38,46,50,64,66,73,77,86	93042	No order for cardiac monitor documented.
43	76880-26	No documentation that ultrasound performed at bedside. No interpretation of results.
88	76857-26	No interpretation of results documented.
Grand Total: 16 procedures not supported out of 47 procedures coded

1 procedure was incorrectly coded:

Chart #	XXXX Coded	TCN Coded	Description
72	36000	36410	Peripheral EJ IV start by MD
Grand Total: 1 procedure incorrectly coded out of 47 procedures coded

2 procedures were missed (documented but not coded):

Chart #	XXXX Coded	TCN Coded	Description
76, 98	-	93042	Rhythm ECG
Grand Total: 2 procedures missed

The total coding variances were as follows:

14 E&M Level of service coding variances

19 19 Ancillary procedure coding variances

33 Total coding variances out of 151 CPT codes considered (104 charts) or 22%

The following modifier variances were noted but not counted as errors:

Chart #	XXXX Coded	TCN Coded	Description
20	29515-54	29515	-54 not required for splinting
1, 12, 19, 24, 42, 50, 51, 53, 54, 76, 78, 81, 91, 98, 104	E&M Code	E&M Code + GC	-GC required for Medicare patients to indicate resident provided care and teaching physician present during key portions
Grand Total: 16 modifier variances

 

 

Physician Documentation Deficiencies:

E. The following documentation deficiencies were identified:

E&M Services: There were 2 instances where inadequate History of Present Illness (HPI) documentation caused The Coding Network’s coders to downcode the E&M code.

Chart #	Potential Code	TCN Coded	Description
52	99285	99283	Inadequate HPI. Physician must complete HPI. Nursing documentation cannot be used.
61	99285	99283	Inadequate HPI.

Rhythm ECG Interpretations: In 2008, the CPT definition concerning documentation requirements for Rhythm ECG interpretations and “at least 12-leads” was modified to the following:

• Have a specific order for the diagnostic;
• Have documentation in the medical record supporting the need for the diagnostic and;
• Have a separate, signed, written and retrievable report and an interpretation of the diagnostic.

In addition, Rhythm ECG services are considered to be appropriate when:

• The order for the diagnostic is triggered by an event or;
• The diagnostic is used to help diagnose the presence or absence of an arrhythmia.

There were 14 instances where no order was documented for the cardiac monitor thereby creating a deficiency which prevented The Coding Network’s coders from assigning code 93042.

Chart #	XXXX Coded	Description
1,6,8,11,14,31,38,46,50,64,66,73,77,86	93042	No order for cardiac monitor documented.

Ultrasound: There were 2 instances where the documentation was incomplete regarding ultrasounds. The documentation must include 1) a statement that the ultrasound was performed bedside and 2) an interpretation of the ultrasound by the ED physician.

Chart #	XXXX Coded	Description
43	76880-26	No documentation that ultrasound performed at bedside. No interpretation of results.
88	76857-26	No interpretation of results documented.

 

1. II. Coding Comparison

104 Chart Sample

The Coding

Code XXXX Network Variance

99281 0 0 0

99282 1 1 0

99283 6 6 0

99284 41 34 +7

99285 52 59 -7

99291 4 4 0

Grand Total: 104 104

Procedures 47 33 +14

1. III. DOLLAR COMPARISON

104 Chart Sample / 38,925 Total Visits

A. Variance Calculation

XXXX The Coding Network

Total Charges Total Charges

$116,426 $118,791

(Average Patient Charge = $1,119) (Average Patient Charge = $1,142)

Sample Variance = $2,365

$1,142 TCN APC - $1,119 XXXX APC = $23 APC Variance (2%)

B. Sample Size Extrapolation to Annual Additional Charges and Collections

1. Projected Annualized Charges and Collections (XXXX APC)

$1,119 XXXX APC x 38,925 Annual Visits* = $43,557,075 Annual Charges

$43,557,075 Annual Charges x 19% Collection Ratio* = $8,275,844 Annual Collections

2. Projected Annualized Charges and Collections (The Coding Network APC)

$1,142 TCN APC x 38,925 Annual Visits* = $44,452,350 Annual Charges

$44,452,350 Annual Charges x 19% Collection Ratio* = $8,445,947 Annual Collections

C. Net Collection Variance

$8,445,947 TCN Projected Annual Collections

- $8,275,844 XXXX Projected Annual Collections

$  170,103 Projected Additional Annual Collections (2% increase)

*Annual visits and Collection Ratio provided by Xxxxx Xxxxxxxx.