The emergency department in a hospital or a stand-alone emergency care center is one of the busiest
facilities in the medical industry. From minor insect bites to severe cardiology issues, providers
working in the emergency department face several odd challenges every day. Due to the sudden nature
of the visit to the emergency room, the usual process of taking down insurance details and running
that information through the system becomes difficult to maintain. It is why most emergency rooms or
emergency departments in healthcare systems face issues with their cash flow. Most healthcare
systems in the recent months are suffering from high staff shortages, making it extremely difficult
for the department to function and maintain a healthy revenue cycle. A professional RCM company
could be the right choice for hospitals to manage their staff shortage challenges and maintain a
good flow of cash in the organization. What are the issues that the emergency department billing
team deals with often? How can you manage those challenges without straining your financial health?
Here are some top solutions from an expert RCM company that can help you.
1.Well-documented ED Charts:
Providers prepare the charts of the patient encounter during the emergency visit. It is the only
place where the patient’s details and recommended treatment plan are stored. As explained earlier,
the hospital billing team often finds that the insurance details or the patient information
submitted during admission are incorrect. It is advisable not to depend on these data points since
the probability of them being wrong is very high.
Here are a few places where the errors could occur:
There are some differences between charts in a standard hospital setting and an emergency
department. In the case of an ED, any patient will always be treated as a new interaction. Hence the
provider must note down the past and present healthcare information during the patient interaction.
Emergency medicine billing requires the billing team to mention the complexity of the medical
condition, ranging from levels 1 to 5, where one is the least complicated and five is the most
complex. The billing team who assigns the code as indicated by the provider’s chart should also
remember to accompany the claim with sufficient medical documentation as proof of the level of a
medical emergency.
Hence it is imperative for the healthcare providers to document in detail the treatment plan they
have in the course for the particular patient. Any discrepancy between the treatment rendered and
the documentation recorded in the charts could lead to painful areas of contention between the payer
and the provider. To avoid any delay with your reimbursement, make sure you submit all the necessary
details in your ED chart.
2.Coding Best Practices:
Both Government and private insurance companies have their designated rulebooks to follow when
claiming an emergency medical service. But for every payer network, the codes should be accompanied
by three explanatory components- the history, the medical examination, and the complexity of medical
decision making. The coding team should be
adept at assigning the required E&M code depending on
the level of complexity of the emergency. Here is how Blue Cross Blue Shield of North Dakota
arranges the ED E&M CPT Codes (Professional Charges) according to their complexity level:
99281: Corresponds to minor conditions and straightforward medical decision making
99282: Corresponds to conditions with low to moderate severity and low complexity medical
decision-making
99283: Corresponds to conditions with moderate severity and moderate complexity medical
decision-making
99284: Corresponds to high severity and moderate complexity medical decision-making conditions. This
code is usually used in a situation where the patient needs urgent evaluation.
99285: Corresponds to high severity and high complexity medical decision-making conditions. This
code is usually used in a situation where the condition could pose a serious life threat or
life-long impairment of physiologic function to the patient.
Upcoding or downcoding are relatively common issues that crop up during emergency medical billing.
The insurance companies want to see the medical documentation to support the claim. It is especially
true when coding at complexity level 4 or 5. A professional and experienced RCM company understands
the pitfalls in this area and can help you avoid them. An RCM company can also maintain a clear
communication channel between the front-end and back-end staff, thus ensuring that no money is left
on the table due to poor communications.
3.Track RCM KPIs:
While many of the problems are common to most emergency departments, every facility or department
within a healthcare system has its unique challenges. Hence it is always advisable to regularly
track revenue cycle management KPIs and see how the trends look. Some of the common KPIs that an RCM
company tracks are:
Days in AR: Ideally, an RCM company aims to keep the days in AR between 0 to 30 days. However, the
numbers can also go above 90 days for ED visits. Make sure that you
reduce the number of AR days
to ensure better revenue flow.
Claim Submission Rate: If you do not send the claims within time, your money might stay on the table
for a long time before it is gone forever. To avoid any such issues in the medical billing
ecosystem, an RCM company makes sure that they submit the correctly filled-up claim within the
shortest possible time. Measure how many claims get submitted in a day versus the revenue generated.
A delay in submission will lead to a delay in payments.
Claim Denial Rate: This metric is undoubtedly the most common yet the most effective KPI you should
track. In case of emergency department visits, following the denial rate will tell you which areas
of the workflow need keen attention. For example, if there are increased number of denials due to a
lack of documentation, work on ED charts in your organization. If the denials are more inclined
towards upcoding or downcoding, make sure you have trained staff to assign the correct codes and
supplement them with sufficient documentation.
A professional RCM company has demonstrated capabilities to handle different medical specialties.
In-house teams of healthcare companies are undoubtedly well-versed in their job. But they often lack
the target-specific expertise or the time to focus on minute details of medical billing. Get in
touch with an experienced RCM company that can help you manage your emergency department coding and
billing and improve your collections.
We hope this blog helped you understand how the solutions from an expert RCM company can radically
change your emergency room billing issues. For further queries, you can comment down below. We will
get back to you. For more updates on healthcare, technology, and management, do not forget to
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