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Latest CASE STUDIES
By Leigh Poland, RHIA, CCS
August 31, 2023
The year 2023 brought significant changes to the E&M (Evaluation and Management) coding landscape. It is critical for coders and healthcare providers to understand how these updates impact documentation and billing practices and accurately assess the medical decision-making (MDM) level. Our team recently analyzed data and insights into observations in the emergency department as well as hospital medicine to gain a better understanding of the impacts of shifting from history and examination to a focus on the complexity of the problem and data review.
In reviewing case examples, it is evident that 2023 revenue is reflecting an upward trend as a result of these guideline changes. We compared metrics from the emergency department provided by the Centers for Medicare and Medicaid Services (CMS) to compare revenue between different time periods. Rather than focus on acuity levels and distribution, our analysis utilized RVU (Relative Value Unit) trends, specifically WRVU (Work RVU) and TRVU (Total RVU). This verified that, since the guidelines were enacted, revenue is on the rise.
However, although revenue is increasing, further analysis reveals scenarios where providers are still missing out on more potential revenue due to documentation gaps. For example, a common error occurs when a coder does not consider the administration of a controlled substance. Additionally, when critical care time is not documented, the opportunity to code and bill for critical care is lost. Similarly, incomplete documentation of ancillary studies, such as EKG findings, can result in missed coding opportunities and revenue loss. Other common coding errors include failing to check for the disposition status, not reviewing the consultation notes with a brief finding when a provider consults with another provider, and not considering life-threatening conditions. Providers can improve their documentation practices by identifying these areas to ensure accurate billing and revenue capture.
Extending the analysis to hospital medicine, similar trends are observed. By categorizing visits into initial, subsequent, and discharge types, initial visits show a decrease in revenue, while subsequent and discharge visits demonstrate an increasing trend. The overall worker view and TRVU data exhibit an upward trajectory, compensating for the initial visit revenue loss.
Analyzing some of these significant changes in the emergency department and hospital medicine provides valuable insights into revenue trends, documentation gaps, and the impacts of new E&M coding guidelines. Documentation of diagnoses, workups, data reviews, and consultation discussions are essential in obtaining accurate and comprehensive documentation to ensure appropriate billing and revenue capture. By understanding these changes, healthcare providers can adapt their practices and optimize revenue generation while delivering quality patient care.
To learn more about optimizing E/M coding for higher reimbursements, check out our recent webinar, “Are You Missing Reimbursements From Your E/M Coding?” AGS Health offers multiple solutions to support your team in optimizing the CPT guidelines and code updates.
Leigh Poland RHIA, CCS
Leigh has over 20 years of coding experience and has worked in the coding and education realm over the last 20 years. Her true passion is coding education making sure coders are equipped to do their job accurately and with excellence. Academically, Leigh has graduated from Louisiana Tech University with a Bachelor of Science. Leigh has had the opportunity to present many times in the past at the AHIMA, ACDIS, and AAPC National Conventions. She has been a guest speaker on AHIMA webinars and has written several articles that were published in the AHIMA Journal. Leigh has traveled the US and internationally providing coding education.
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