More-complex care, not fraud, behind higher ER billing, doc argues

Posted by: Aparna Prasad

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Fraud isn't at the root of a spike in providers' billing for emergency services, a new opinion piece in the New England Journal of Medicine asserts. 

Rather, the piece's author writes, higher ER billing reflects both increasingly complex care provided in emergency departments over the past decade and more-accurate coding of that care.

The emergency department has become "a central staging area" for the acutely ill, according to Dr. Stephen Pitts, associate professor in the emergency medicine department at Emory University School of Medicine, Atlanta. The perspective piece notes that Level 5—the most serious—ED visits have increased from 27% of all Medicare discharges to 48% between 2001 and 2010. The most common symptoms leading to these discharges—abdominal pain, chest pain and shortness of breath—can now be diagnosed and risk-stratified in the emergency department using high-tech imaging, leading to fewer calls for surgical consultations and fewer hospitalizations. 

Also contributing to higher billing is an "increasingly interventionist ED practice style" that has led to the initiation of more laboratory tests and initiation of intravenous fluids, Pitts wrote.

"Whether this trend has truly improved patient safety and quality of care is unknown, but it has certainly increased the complexity of the medical decision-making component of documentation, which translates into higher physician billing," Pitts wrote.

Defensive medicine, too, may also play a role, he said.

"Failure to diagnose patients' conditions carries heavy penalties for ED physicians and hospitals, whereas 'overuse' of technology is ill-defined, and penalties for it are less direct," Pitts wrote. 

Electronic health-record systems help emergency-room personnel document all care provided by "presenting clickable check-boxes that easily satisfy coding-complexity criteria," he said. This ensures that "no billable action goes unnoticed," he wrote—but that doesn't mean fraud is occurring, as a federal auditor's report from this fall on evaluation and management visits suggested.

Read full article here.

Topics: EHR Software, EMR System

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