Case mix, upcoding fueling ‘high-intensity’ ED billing

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High-intensity billing during “treat and release” emergency department stays rose significantly from 2006 to 2019, and was partially fueled by factors such as changes in case mix and service offering expansions, according to a new study in Health Affairs.

The analysis was conducted in part as a response to complaints about fraudulent upcoding, which may be common across treat-and-release ED visits. While upcoding is a factor, it doesn’t account for the trend in and of itself.

At the beginning of the study period, high-intensity billing comprised 4.8% of treat-and-release visits. By 2019, that figure had jumped to 19.2%. Health Affairs did note, however, that 47% of that growth was expected, since over that time patients with more serious conditions comprised a bigger percentage of treat-and-release visits, owing largely to changes in administrative measures for case mix and care services.

In addition to upcoding, other reasons for the shifting landscape include a correction for historical downcoding, when coding practices were simpler, and broader changes in the evolution of care in the ER.

High-intensity billing was defined as ED visits that included a CPT code signifying high complexity or critical care.

WHAT’S THE IMPACT

The authors framed coding practices as one element of an ongoing “tug-of-war” between payers and providers.

The information is being published as the Centers for Medicare and Medicaid Services has recently finalized a reduction in the Medicare Physician Fee Schedule conversion factor, which means ED physicians are now facing reimbursement reductions. The reduction from CMS would disproportionately affect reimbursement rates for high-intensity care, according to Health Affairs.

And after implementation of the No Surprises Act, EDs are likely to see lower commercial rates. 

Coding is only one piece of the puzzle. Changes and evolutions have occurred in emergency care, such as advanced imaging studies for the diagnosis of acute abdominal pain, which in 2019 overtook musculoskeletal complaints as the most common primary diagnostic grouping. 

Observation care and clinical pathways have also grown for common but potentially dangerous complaints, and this might direct more low-acuity complaints to urgent care centers, authors wrote. Meanwhile, more resources are being directed to emergency departments, potentially leading to more intense emergency care.

Another factor fueling the trend, according to Health Affairs, is the pressure on hospitals to reduce spending, which has driven down low-valuer admissions and forced EDs to step up in response, all while the U.S. population ages and deals with more chronic conditions.

THE LARGER TREND

EDs have advanced a number of innovations in order to combat these trends, authors said, but these efforts may not be fully captured in claims data, and in turn may contribute to the climb in high-intensity billing.

They said that future policy work should tackle these controversies with a mind on the “broader forces acting on the finances underlying emergency care.”
 

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