Emergency Department Directors Academy Phase I Fall 2019 Billing and Coding DESCRIPTION Most emergency departments generate money the old fashioned way – they earn it by caring for patients. The key is to convince the payers that the providers are due reimbursement for the clinical services provided. Several basic principles of documentation, E/M coding, CPT definitions, RVUs, billing, charge structure, write-offs, bad-debt, accountability, compliance, etc., will be discussed. Several time tested methods of improving reimbursement will be discussed, as will be methods to monitor your ED’s performance in this critical area. Additionally, the presenter will identify and suggest how to prevent billing, coding, and supervision issues subject to fraud and abuse. OBJECTIVES

• Define basic terminology of the billing and coding system. • Describe the specific components of the billing process. • Explain the professional and technical components of E/M coding and billing. • Identify how E/M coding and billing interrelates to the hospital reimbursement. • Differentiate between billing performed by a group, hospital, or billing company with respect to general approach, ongoing

monitoring and management. • Identify areas of emergency billing, coding, and resident supervision where fraud/abuse can take place. • Billing and Coding

11/14/2019, 10:15 AM - 11:45 AM FACULTY: Michael A. Granovsky, MD, CPC, FACEP BIOGRAPHY: Doctor Granovsky is the President of Logix Health, a national ED coding and billing company processing over 10,000,000 annual encounters. Following completion of his Emergency Medicine residency Dr. Granovsky went on to found Greater Washington Emergency Physicians, serving as the Chief Financial Officer. Dr. Granovsky then attained a coding certification, followed by an ED subspecialty certification in coding and reimbursement and currently is one of the few MDs in the country who is also a certified coder. Dr. Granovsky is the Director of the American College of Emergency Physicians (ACEP) Reimbursement course, and leads the education efforts of ACEPs National Coding and Nomenclature Advisory Committee. He is the immediate past Chairman of National ACEP’s Reimbursement Committee as well as the reimbursement subject matter expert to multiple task forces including quality measure development, episodes of care, ACEP’s CEDR QCDR, and Out of Network Fair Payment coalition. Dr. Granovsky serves as editor for both ED Coding Alert and the American Academy of Professional Coders (AAPC) ED Specialty Coding Certification Exam. A nationally recognized expert Dr. Granovsky has been recognized with numerous national speaking awards including ACEP Speaker of The Year. DISCLOSURE: (+) No significant financial relationships to disclose

Billing and Coding EDDA November 2019

Michael Granovsky MD, CPC, FACEP

President, LogixHealth

The Is Who We Are!The Safety Net

140 million visits, 39 million related to injury, >60% of hospital admissions, 4% of the work force- >50% of the care for Medicaid and CHIP

▪ Accounts Receivable A/R- services that have been billed for, but $ not collected ‒ Patient seen and treated‒ Chart coded‒ Bill sent

Money not received yet… “It’s out there.”

Billing Terms-Accounts Receivable

Days In Accounts Receivable

▪ Days in A/R- The average number of days it takes to collect on a bill.‒ Total $ in AR/Average daily charges‒ $2,000,000 AR/$50,000 daily charges = 40 days‒ Benchmark for how long it takes to collect your

money▪ Best Practice now < 40 days

‒ Many variables: payer mix, registration data, chart flow, coding turnaround, billing efficiency

AR Report: Ideal Example

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18

Charges $1,109,679 $976,023 $988,565 $948,619 $981,894 $986,410 $961,432Collections $246,484 $217,510 $240,462 $253,666 $235,618 $229,865 $242,700# of Pts 2,695 2,650 2,623 2,807* 2,713 2,709 2,672Refunds $81 $893 $295 $669 $486 $0 $279Cont Adjs $292,752 $246,678 $272,409 $282,819 $265,494 $257,069 $246,261Free Care $2,370 $3,253 $2,214 $1,175 $3,573 $3,830 $2,373Bad Debt $62,478 $56,971 $63,463 $55,653 $63,134 $88,699 $44,236A/R* $1,895,113 $1,847,617 $1,897,928 $2,073,904 $1,928,465 $1,896,412 $1,851,553Days* 37 38 37 41 40 38 38

Billing Terms: Aging Analysis

▪ Aging Analysis- lets you know how old your A/R is in 30 day increments:

▪ 0-30, 30-60,60-90,90-120…▪ May even be broken down by payer Aged Trial

Balance‒ Medicare may run 21 days‒ Medicaid 30-90 days (variable)‒ Self pay 120 days‒ Worker’s Comp. 180 days

▪ Depends on direct electronic submission and optimizing clean first pass claims

Days To Bill Drop

▪ The number of days from the date of service until a bill is sent to the patient or insurance carrier

▪ Variable standards benchmark 3 days▪ 3 days maximizes efficiency▪ Affects practice cash flow▪ Many Steps:

‒ Chart completion, data file transfer, coding (is there a back log), data entry (should no longer exist), demographic verification, claim scrubber (maximize clean first pass), bill sent

Dunning Cycle

▪ Schedule of claims and statements▪ Payer specific cycles enhance cash flow

‒ Medicare processes Wednesday‒ BCBS processes on Tuesday‒ Clearing House batches, doesn’t

coordinate with payer cycles‒ Best Practice Submit directly

electronically and receive by EFTThe longer “it’s out there” …

the harder it is to collect!

Shine A Light On The Black Hole of Billing

▪ FILE and POST Electronically – discrete steps▪ 14-21 days for maximal $

‒ Medicare, Medicaid, BCBS, Aetna, Cigna, United…..

‒ 837 electronic claim submission‒ 997/999 claim received ‒ 835 electronic remittance (EOB shows payment

and denials)‒ Electronic Funds Transfer (EFT)- direct deposit

▪ Best Practice: No Clearing House Involved▪ All electronic process

USE A LOCKBOX: KNOW WHEN PAYMENTS ARRIVE

▪ $ Collected/Total Charges (as a %)▪ Not “apples to apples”

‒ Impacted by pricing structure ‒ Impacted by payer mix‒ 99283 charge $180

• HMO reimburses $60 ….30% Collection Ratio • Comm. reimburses $90…50% Collection ratio

▪ Whole state of MD runs 42% (vague term)

Gross Collection Ratio

Net Collection Ratio

Net Collection Ratio: Total $$ charged-contractually mandated

discounts…all the collectible $

See 50 HMO patients coded 99283 ($180 charge)Total charges: $180 X 50 = $9000Total collectibles: $60 X 50 = $3000

Receive payment on 48 patients: 48 X $60 = $2880Gross collection ratio:$2880/$9000 = 32% ?badNet collection ratio: $2880/ $3000 = 96% good

Good indicator of Billing company billing efficiencyBenchmark > 95%

Apples to Apples$ Collected per Billed Visit

▪ The ultimate distilled measure of revenue for each patient visit.

▪ Allow time for account to mature‒ 6 month look back

▪ High End $200▪ Suburban $140▪ Urban $80….hospital subsidy

Billing Functionality:Best Practices and Benchmarks

▪ Days in AR: AR/Avg. daily charges <40 days▪ Bill drop 3 days▪ Submit electronically to all enabled payers

‒ No Clearing House▪ Net Collection Ratio: $ collected / All the collectible

money 95%▪ $ collected per patient maximized

‒ Track trends▪ Steady practice cash flow!

The Revenue Chain

CredentialProvider

Patient Presents

Registration DocumentRecord

Reconcile

Coding ChargeEntry

Verify Scrub

Bill Drop

Follow UpDenial Mgt.

Payment

Credentialing

▪ Tight timeline▪ Robust provider enrollment team

‒ Full software package▪ Off the shelf application package

‒ Project▪ Measure turnaround time from providers

‒ 1-2 wks. max▪ How much revenue is waiting for provider numbers?

‒ Missing Provider Number Receivables Report▪ No provider numbers = no pay!

‒ Benchmark….100% credentialing

Hospital Registration Data

▪ Measure the amount of bad insurance info.▪ Get detailed insurance data crosswalks

‒ Not just “BCBS” use insurance dictionary from the hospital…over 1,000 discrete payers

▪ Clean Claim Report: ‒ Benchmark > 95% first pass clean claims‒ Track denial reasons: Patient ineligible

▪ Billing agent should work closely with:‒ Hospital IT…re-query/real time updates‒ Registration staff scripting project‒ Best Practice: Direct Electronic Download

Chart Reconciliation Report

▪ Account for every chart! Lost record > $100• 5 hours of clerical time

‒ ED registration log = the denominator‒ Electronic download and weekly aged

reconciliation (PROJECT)‒ Purposely not billed: Private physician, LWBS‒ Missing: (Often admissions and transfers)‒ Incomplete: Sent back to the provider pending

additional documentation…should be agedBest Practice: electronic download of the ED log and

daily updated reconciliation reports

Formula- account for 100% of records#Billed#Purposely not billed#Incomplete

+ #Missing#Patients on ED Log

Benchmark: MISSING SHOULD BE < 0.5% at 2 mos

At 60 days >99.5% of records received

Reconciliation Formula

Reconciliation Report Detail:100 Patients on ED Log October 3rd

▪ 91 Billed▪ 4 Purposely not billed

‒ 2 Suture Removals‒ 1 Private MD‒ 1 LWBS

▪ 3 Sent back to doctor (incomplete)‒ 1 Dr. Jones October 15‒ 1 Dr. Smith October 17‒ 1 Dr. Green October 17

▪ 2 Still missing

Reconciliation Reports- Trend Monthly

2

1 1 1

6

7

9

5

3

4

6

1

0

2

4

6

8

10

Oct Dec Feb Apr Jun Aug

Charts Not ReceivedTrend

8

7

9

8

11

9

7

10

13

8

7

6

0

2

4

6

8

10

12

14

Oct Dec Feb Apr Jun Aug

Chart IncompleteTrend

ED Log Reconciliation Value

Let’s do a little math: ▪ 3 charts per day

‒ 365 X 3= 1,095 charts per year. ‒ (1,095) X ($120/chart)=$131,400 per year.

▪ How many unbilled charts do you have?‒ ROI: How much additional revenue will an

administrative assistant/clerk generate?Best Practice/Project: Daily Reconciliation report.

Useful reports enable important changes!

Billing Processes: Best Practices and Benchmarks

▪ Tight credentialing process‒ 100% credentialed providers

▪ 95% Clean first pass claims▪ Direct electronic downloads:

‒ ED Census Log‒ ED Demographic File

▪ Full daily electronic reconciliation‒ 99.5% of charts received

within 60 days

The Power of E/M Benchmarking

Where Are The RVUs?

▪ 85% of typical ED doc’s revenue derived from 99281-99285…track key metrics‒ E/M distribution‒ Average E/M‒ Feedback report

▪ Critical Care brings up to 89%▪ Widen the lens to 100% ▪ RVUs per patient

‒ Includes proceduresTrack the important metrics!

2019 Drilling Down on E/M RVUs

0%100%200%300%400%500%600%700%

99281 99282 99283 99284 99285 99291

0.601.17

1.75

3.32

4.89

6.28

The 89% Breakdown:RVU Contribution By Code For E/M Services

4%

40%

30%

12%2%

1%

Benchmarking Your Coding

▪ Majority of revenue derived from appropriate E/M levels

▪ Benchmark data- Project‒ Medicare, private payer, acuity

predictors▪ Common admission benchmarks as 85s▪ 55/45 split between 99284 and 99283▪ 99281 and 99282- low due to high copays▪ Critical care benchmarking

‒ 4% - 6% for most groups‒ .2 - .3 X the admission rate

▪ 40,000 visit ED, level 2 trauma, Cath Center▪ Admit Rate 24%▪ Sample E/M Distribution:

99281 1% 99284 33%99282 3% 99285 30%99283 28% 99291 5%

PROJECT:Compare and benchmark your E/M distribution

Benchmarking Example

Benchmark E/M Distribution

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

99281 99282 99283 99284 99285 99291

1.03.0

28.0

33.030.0

5.0

Professional Group E/M Distribution

E/M Trends Drive ChargesBenchmark Against Yourself: Rolling 12 Months

Evaluation & ManagementDistribution Analysis

CPT Jun Jul Aug Sep Oct Nov12 Month Average

99281 1% 1% 1% 1% 0% 1% 1%

99282 3% 2% 3% 5% 3% 2% 3%

99283 27% 27% 29% 29% 28% 27% 28%

99284 33% 31% 32% 34% 33% 34% 33%

99285 30% 29% 29% 32% 29% 31% 30%

99291 5% 5% 5% 4% 5% 5% 5%

Billing Reports: Average E/M

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3.38 3.4 3.44 3.51 3.52 3.6 3.61 3.76 3.77 3.813.98 4.01 4.02 4.03 4.08

4.27

Physician Average E/M

Billing Reports: Average RVU/Patient

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2.87 2.92 2.97 3.02 3.06 3.16 3.24 3.24 3.34 3.46 3.51 3.56 3.57 3.653.89

Average RVU/Patient

Benchmarking Provider E/M Distribution

0%5%

10%15%20%25%30%35%40%45%50%

99281 99282 99283 99284 99285 99291

0.00% 0.60%

28.10%

32.40% 32.90%

6.00%0.00% 1.40%

47.00%

29.90%

19.10%

2.50%

Professional E/M Distribution

Group Average Provider 129

National Medicare BESS Data

0%

10%

20%

30%

40%

50%

60%

99281 99282 99283 99284 99285 99291

0.2% 1.5%

13.5%

25.2%

52.2%

7.4%

Medicare ED E/M Distribution

Managing Documentation and Coding

▪ Documentation/Coding are the weak link in the revenue process‒ Need a recurring education program

• Example records returned to individual physicians

• Formal didactics• Track provider feedback

▪ Best Practice: RVU and feedback reports monthly

Coding Reports:Documentation Feedback

▪ Feedback reports by provider • HPI• ROS• PFSH• PE

▪ Critical Care Feedback‒ Possible Critical Care Cases

• Acute MI

Feed Back Report and Follow Up Process

Provider Documentation three month trend

Provider June July August

Provider A X X X

Provider B ROS ROS, Exam ROS, PFSHx

Provider C ROS ROS* X

Provider D CC ROS* X

Provider E PFSHx X X

Coding Benchmark Reports to Watch

▪ Overall E/M Distribution▪ Medicare E/M Distribution▪ Average E/M per patient for the

group and by individual provider▪ RVUs per patient for the group and

by provider▪ Feedback Report

Coding: Benchmarking and Best Practices

▪ E/M Distribution Benchmarks‒ Benchmarking 85s‒ Benchmarking Critical Care‒ PROJECT

▪ Solid education and feedback program▪ Need sophisticated coding methodology▪ Accurate physician documentation

‒ No Downcodes‒ Utilize all documentation tools!

Billing- Turning Your Hard Work Into Revenue

Managing The Billing Process

▪ Track the important metrics▪ Overall size of the AR

‒ 40K visits runs ~ $2m‒ Days in AR-look for trends… benchmark < 40

increasing days = danger sign!‒ Follow Gross and Net collection ratio‒ Maximize $ collected per patient

• Allow accounts to mature▪ Gross monthly revenue should be steady!▪ Watch gross charges as an early warning sign

Billing Report: Mastering The Terms

Executive Summary: Charges, Collections and A/R Analysis

Aug Sep Oct Nov Dec Total

Charges* $1,770,746 $1,822,473 $1,768,146 $1,703,243 $1,851,191 $8,415,799

Collections* $716,148 $770,177 $777,442 $748,679 $702,914 $2,315,360# of

Patients* 3,052 3,425 3,212 3,158 3,512 15,759

Refunds* $3,846 $3,799 $3,723 $4,043 $3,325 $8,098

Cont. Adjs* $629,306 $608,797 $669,277 $659,878 $670,200 $2,837,457

Free Care* $4,875 $3,585 $3,535 $4,979 $3,471 $16,570

Bad Debt* $101,845 $108,090 $74,814 $103,341 $119,915 $579,006

A/R* $2,114,447 $2,186,279 $2,031,080 $2,020,489 $2,145,504 $2,035,504

AR Days* 39 39 37 36 38 36

Billing Practice Performance Reports:Date of Service Analysis

Date of Service Analysis

CPT March April May June July Total

Total Charges $1,808,884 $1,821,390 $1,815,147 $1,465,803 $1,852,778 $8,664,002

# of Visits 3,219 3,313 3,304 3,030* 3,276 16,242

AvgChg/Pt.* $462 $463 $459 $460 $461 $461

Collections $650,452 $643,591 $644,899 $624,791 $690,779 $2,634,511

AvgCollect/Pt.* $189 $189 $188 $190* $191 $189

The 6 month look back

Metrics to Monitor

▪ Days in AR - Should not trend up‒ Confounder volume increase

▪ Contractual adjustments shouldn’t spike up▪ Monthly collections should be steady▪ Average charge per patient – small variations▪ Dollars collected per patient – tight range

‒ Allow accounts to mature▪ Watch gross charges and your E/M

distribution

Aged Trial Balance (ATB)

▪ Aging Analysis- a table displaying the A/R age by payer‒ 0-30 days, 30-60 days, 60-90 days,

90-120 days‒ Increase $$$ = warning sign!‒ Un-credentialed physicians‒ Clearing House failure‒ Billing company data file transfer failure‒ Alarm bells- monitor top 5 payers

• Private pay increasing 45,60,75,….• BCBS• Medicare increasing

We Have A Problem!

ATB Warning SignsIncrease $$$ Far Out

PayorCategory 0 - 30 31 - 60 61 - 90 91 - 120 *121 -150 151 - 180 Total

Blue Shield $66,567 $23,476 $18,325 $5,567 $632 $67 $107,025

Medicaid $7,928 $2,261 $2,051 $1,408 $781 $232 $16,521

Aetna $23,439 $37,338 $48,116 $72,184 **$111,360 $3,744 $297,116

My Cash Is Down

▪ Go Back 60 – 120 Days‒ Volume‒ Charge per patient …E/M Distribution‒ Credentialing‒ Electronic Submission process

▪ Carrier Specific Issues‒ Contracted vs Non Par Rates

▪ Payer Policy changes‒ No Longer paying PAs at full fee schedule‒ Not paying for procedures

▪ Discounting of E/M with procedure‒ Not honoring 25 modifier

▪ Coding has drifted downward▪ E/M auto downcodes

My Cash Is Down

BCBS Down-coding 99284/99285

Auto-Downcoding simply based upon Diagnosis!

Who Does the Coding?

▪ Hospital – traditionally not good at ED coding‒ Low charges, signs and symptoms, not their $

▪ Physicians – typically not trained in coding rules, inefficient use of time, compliance probs.

▪ In House Professional coders▪ EHR- lowest common denominator, indemnification

failure ▪ Outside Coding Company

How Do You Choose?

▪ Availability and quality of personnel▪ ED specialized coders

‒ Significant front end training process‒ Ongoing didactics, CEUs, and updates

▪ Data entry personnel, electronic downloads and insurance verifications, claims posting, and denial follow up, and costly billing system

▪ Compliance Issues: MD is responsible▪ Gross to net comparison…a good coding

and billing company needs to increase physician revenue

Cost vs. Accuracy: CPT Coding

▪ Cost: $3 - $5 per visit▪ Productivity: 15 - 25

charts per hour

▪ Cost: $2 - $3 per visit▪ Productivity: 35 - 50

charts per hour

▪ Supervision▪ Internal Audits▪ Feedback

process▪ Audit Defense

Coding- Why Does it Matter?

▪ Coding and documentation is simply the process of communicating to the payer your concerns and thought process

▪ The payer does not have the following:‒ The chart‒ The patient’s perspective on the tx. received‒ The ability to talk to the treating physician

▪ The payer receives (electronically) a series of 5 digit codes representing your care

Your documentation must empower/allow the coder to accurately report the work performed

Documentation Guidelines:Focus on Complex Cases

Level HPI ROS PFSoc PE

1 1 0 0 1

2 1 1 0 2

3 1 1 0 2

4 4 2 1 5

5 4 10 2 8

History of Present Illness

▪ Location – left sided chest pain ▪ Context – while shoveling snow▪ Quality – sharp chest pain▪ Timing – worse at night▪ Severity – moderate chest pain▪ Duration –10 minutes ▪ Modifying Factors – worse with exertion▪ Associated Signs and Symptoms – diaphoresis

This is the case specific detail that makes the patient “come to life” …antidote to “cloning”

HPI Killers

LEVEL 99281 99282 99283 99284 99285# HPI 1-3 1-3 1-3 4 4

RVUs 0.60 1.17 1.75 3.32 4.89

Big Cost of HPI Errors…

▪ Some basic math:‒ 8 hour shift‒ 2 patients per hour 16 patients‒ 3 RVUs per patient 48 RVUs‒ 6.0 RVUs per hour

Or 1 HPI Downcode: 4.89 to 1.75 RVUsLoss of 3.14 RVUs… .4 RVUs/Hr

Down to 5.6 RVUs/Hour!

Billing Reports: RVU/Hour

0123456789

10

A B C D E F G H I J

5.00 5.20 5.40 5.60 5.80 6.00 6.20 6.40 6.60 7.00

RVUs per Hour Quarterly Bonus Q4 2018

Review of Systems (14)

▪ Allergic/Immunologic▪ Cardiovascular▪ Constitutional Symptoms ▪ Ears, Nose, Mouth,

Throat▪ Endocrine▪ Eye▪ Gastrointestinal

▪ Genitourinary▪ Hematologic/Lymph▪ Integumentary▪ Musculoskeletal▪ Neurological▪ Psychiatric▪ Respiratory

Do Not Over Document for Low Level Cases

Review of Systems (ROS)

▪ 99282/99283 – 1 system ‒ (mild nausea)

▪ 99284 : 2-9 systems‒ (diarrhea/dehydration/IVF)

▪ 99285 - 10 systems ‒ (Diverticulitis/CT

Scan/Narcotics)Need 10 ROS for 99285!

High Complexity cases typically require 10 ROS

99284 requires a minimum of 2

ROS RVU Killers

▪ 78 y.o. admitted with right chest pain

▪ 89 year old with SOB and weakness tele admit

99285 now 99284 …. Loss of 1.57 RVUs!

ROS Well Documented

▪ Pat. admitted with PE▪ Rich ROS detail▪ Pertinent positives documented

The CMS History Caveat

“If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstances which precludes obtaining a history.” CMS 1995 Documentation Guidelines

▪ You must document the reason history is not obtained in the record.‒ NH patient with dementia‒ Postictal

History Caveat

▪ NH patient with advanced dementia and DKA:

▪ 73 year old Poor historian with UTI, fever, and dehydration

CPT Acuity Caveat

▪ 99285 requires: ‒ Comprehensive History‒ Comprehensive Exam‒ High Level Medical Decision Making

Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the

urgency of the patient's clinical condition and/or mental status:

CPT 2019

Acuity Caveat- Well Documented

Documentation Basic Best Practices

▪ 4 HPI with case specific detail▪ Recognize high complexity cases▪ Beware overuse of ROS and PE macros

‒ Include pertinent positives and negatives▪ Document Past/Family/Social Hx▪ Cleary state history caveat▪ Utilize the acuity caveat

Coding and BillingBenchmarking and Best Practices

▪ Electronic processes‒ No clearing house

▪ 100% credentialed providers - Project

▪ 99.5% of records received at 60 days - Project

▪ 3 days to bill drop▪ Consistent charges and

monthly cash flow▪ Days in AR < 40 days▪ Maximized $$$ collected

per patient

▪ Net Collections ratio 95%▪ 95% clean first pass

claims▪ Benchmark group E/M

distribution- Project▪ Medicare E/M

Distribution▪ RVUs/Patient

‒ Group and provider▪ Feedback Report

Contact Information

Michael Granovsky MD CPC FACEPPresident LogixHealth

mgranovsky@logixhealth.com781.280.1575

www.logixhealth.com