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Over the past few years, numerous articles and fraud alerts have shown that billing in the emergency department (ED) may be a high risk area for fraudulent billing. Because of the impact of the electronic health record and documentation indicating higher levels of service being performed, it may seem that documentation can be worded to allow for overinflating and upcoding of visit levels.
It is important that the practitioners documenting have a clear understanding of the rules and regulations. Especially, to make sure that they are billing correct diagnoses and procedures for their visits.
Documentation of the medical visit must support the three key levels of service. Specifically, required to bill for an ED visit as defined by Current Procedural Terminology (CPT). All three components must be met at the correct level of service required to bill for a specific code. Critical care services are based on the type of service. Also, the total time a physician spends in caring for the patient. Without appropriate documentation of time, critical care codes cannot be used.
Many insurance companies have medical necessity guidelines, which review documentation of the patient's diagnoses codes. Specifically, to determine if they will cover the procedure(s) performed. With the implementation of ICD-10-CM this past year, there are more code choices available. The selection of the correct code should mirror the documentation. Especially, which must be sufficient to support the code selected on the bill.
There are many codes that are nonspecific, such as asthma, which might be appropriately used as a secondary code if a patient is being treated for another condition and the asthma is chronic and not causing severe problems. However, if the patient is being seen in the ED for an acute asthma attack, the more specific code to show that level of severity must be assigned to justify why the patient is being seen and can sometimes justify a high level of service because the patient's condition was serious and/or complicated. Diagnosis codes should be assigned and should include any secondary conditions that are present at the time of the encounter that impact the care and decisions made to determine the correct course of treatment.
In summary, documentation should support the care provided to the patient. If documentation is incomplete or inaccurate, this can impact the correct reimbursement received for the treatment provided. Documentation is used to select the appropriate codes for both diagnosis and procedures performed during the visit. These codes should be accurate and complete in order to tell the complete story of the patient's condition. Also, the services provided, to show that they were medically necessary and appropriate.
MEDHOST has partnered with TruCode®, a top provider of encoder technology. This partnership allows TruCode to offer its advanced knowledge-based encoder to MEDHOST customers. Especially, with the company's inpatient electronic health record (EHR). TruCode (Alpharetta, GA) is an innovator in the medical coding software market and provides an encoder application, components and web services to the hospital, consulting and Healthcare IT marketplace. Its software is used by more than 1,800 professionals in more than 450 healthcare organizations. TruCode was the first to release a complete ICD-10-CM encoder and deliver encoder components via web services. For more information visit: www.trucode.com
