Updated on: January 29, 2014

Time, Money and Coding in the ED Creates Perfect Storm

By Susan Miller, CSS
Original story posted on: November 20, 2013

The emergency department (ED) is a hospital’s front door to the public. It’s also an open back window for revenue loss. ED volumes continue to rise while reimbursements drop. And according to recent executive surveys, there is no end in sight. Long wait times, primary care shortages, and an underinsured population combine to fuel executive concerns.

Furthermore, technology applications meant to bolster ED productivity also hinder physician-patient relations. The average percentage of time spent on physician data entry into the EMR/EHR is 43 percent (well above the 28 percent figure for direct patient interaction).[i] The same study reports that the average ED physician racks up nearly “4,000 mouse clicks during a shift.” Will ICD-10 documentation and coding make matters worse? Perhaps.


ICD-10 and the ED: A Matter of Assignment

The correct coding and billing of ED cases involves a mixed cauldron of clinical coding expertise. Some code assignments are performed by hospital coders, some by ED physician groups, and still others by third-party outsourced companies.

While hospital coders are expected to preserve ownership of the hospital component of ED coding in ICD-10, physician coding will still be managed by an outside party (either the ED physician group or a third-party vendor). Yes, ICD-10 challenges are role-based. However, all parties are required to assign ICD-10 codes for diagnoses documented and reported in the ED effective October 1, 2014.

There is some reprieve with ED procedures and E&M leveling. Procedures performed in the ED will continue to be assigned a CPT code, and accompanying E&M levels remain the same. No change is expected in these areas. The biggest challenge here will be the maintenance and utilization of two different coding nomenclatures for the same case.

Seven Tasks to Start Next Week

To get started on preparing your ED for ICD-10, the following seven tasks should be considered:

  • Extend ICD-10 education to all those involved in ED diagnosis coding.
  • Extend dual coding efforts to ED cases.
  • Assess ED diagnosis documentation for ICD-10 gaps.
  • Audit your charging, coding, billing, and reimbursement workflows.
  • Include ED cases in end-to-end testing with payers.
  • Inform ED physicians of new, more detailed documentation requirements for diagnosis.
  • Update documentation templates within ED and EMR software (yes, more clicks).

If your organization is behind on ICD-10 budgets and preparation resources, focus the same seven steps listed above to two known areas of ED revenue concern: injuries and asthma.

Injuries and Asthma: Key Areas of Concern

Among the top ten ED diagnoses for most hospitals, those associated with injuries, traumas, and asthma represent the majority of cases—and the most diagnosis code changes. For injuries and trauma, ICD-10 expands the number of potential codes by requiring additional documentation of specific anatomical location, exact type of injury, timing of encounter, and cause of injury. ED documentation for injuries and traumas to the finest level of specificity is essential and should be shored up now, not later.

Similarly, for asthma coding, new definitions and terms will be in place for ICD-10 coding, including intermittent, mild, moderate, and severe persistent. Clinical documentation of these cases within the ED must be assessed, gaps identified, and education conducted to ensure:

  • Clinicians and coders are aware of new documentation requirements.
  • Documentation templates are updated.
  • End-to-end payer testing for asthma cases is conducted. 

These are just two areas of concern for ED coding and reimbursement in ICD-10. Assess your existing ED case mix to identify that diagnoses (high volume or high value) are of primary concern for your organization. 

About the Author

Susan Miller, CCS, is the manager of quality assurance and compliance for H.I.M On Call, Inc.

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[i] “4000 Clicks: a productivity analysis of electronic medical records in a community hospital ED”. Hill, Robert, Sears, Lynn Marie and Melanson, Scott W. American Journal of Emergency Medicine. September 2013. Available online at: http://www.ajemjournal.com/article/S0735-6757(13)00405-1/abstract

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.