Best Practices in Emergency Department Coding

Emergency departments have one of the most hectic and fast-paced environments in healthcare units and they often have the highest volumes of patients coming in and procedures happening. Emergency department (ED) doctors order several diagnostic tests and perform surgical procedures necessary to provide critical care and save patients. These very qualities of emergency departments create unique challenges in their documentation, coding and billing. 

Challenges in ED Coding

Accurate ED coding is crucial for not just the continued care of the patients but a seamless claims process and for maintaining a positive hospital revenue cycle. Here are the challenges faced by healthcare providers when it comes to emergency department coding. 

As discussed earlier, the stressful, fast-paced and high-volume environment of emergency departments requires speedy-yet-accurate clinical decision-making and quicker execution from the doctors, nurses and other medical professionals in the facility. This severely reduces the timeframe available for clinical documentation (the physicians’ notes are often not very expansive) as well as the finding out if the patient has insurance coverage or explaining the financial implications at length to them. This leads to under-coding, improper documentation for coders, inadequate supporting documents, etc. This, in turn, affects billing and the entire revenue cycle management process. 

The second challenge is the improper coordination between the ED physicians, nurses and other facility staff. This often leads to information silos which adversely affect the efficiency and accuracy of coding. 

The third challenge is that longer ED stays (over 24 hours) attract closer scrutiny and audits. They need to be supported with proper documentation so that coders can review and classify ED care and observation care appropriately. 

Lastly, ED coding is often outsourced to offshore coders or to third parties to reduce the drudgery of doctors and nurses. However, these coders may not have the requisite expertise and nuanced understanding of the ED environment to code effectively. 

Best Practices in ED Coding

2. Accurately determine the E/M Levels 

Evaluation and Management (E/M) levels directly impact the level of clinical decision-making as they provide the complete picture of the diagnosis and the treatment/ care that is to be provided to the patient during their ED stay, follow-ups and discharge/ disposition. For accurate E/M level determination, it is key to understand the presenting problem, patient history and findings of the physical examination.  

2. Ensure cooperation between the ED Physicians, facility staff and coders

Information silos and lack of cooperation between ED physicians, nurses, facility staff and coders are detrimental to the hospital revenue cycle management.  For instance, facility codes are flexible and can be built by the hospital while physician codes are standardized. While building the facility codes, a lack of cooperation/ coordination between these different parties will cause a lack of information and in turn, lead to under-coding. 

3. Educate and train doctors and nurses on documentation requirements and diagnostic specificity

This reduces under-coding, improper documentation and claims denials, thereby, helping to improve the revenue cycle yield. 

4. Onboard coders/ coding services with expertise in emergency departments

ED physicians and nurses may not have very expansive notes. There are often discrepancies in the notes/ documentation of doctors, nurses and support staff as well as discrepancies in the doctors’ notes and orders in the emergency departments owing to the shortened timeframes and stressful environment. In such a context, it is crucial that coders have a nuanced understanding of the ED environment and constantly and closely review the notes, documentation and Q/A to avoid institutionalizing misunderstandings and discrepancies and incorporate coding errors into the institutional legacy. 

There are other nuances only expert ED coders will understand. For instance, the time of intervention vs intensity of resources used. Some procedures/ services are not time-consuming but are resource-intensive. So, coders need to understand this nuance if they are to build a strong facility billing code. 

Atom USA, with its team of medical coders who are American Health Information Management Association (AHIMA)- and American Academy of Professional Coders (AAPC)-certified medical coders, experts in medical coding services and experienced healthcare practitioners, offers customized ED coding solutions to help you improve your revenue cycle yield through high-quality, accurate coding


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