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As the term ‘emergency’ suggests, Emergency department(ED) is the most sought after option patients immediately resort to, for acute illness or trauma cases. ED provides primary evaluation and management service and any procedures, if performed. However, majority of the ED physicians are facing a dent in their pockets for the losses they encounter due to lack of medical necessity, down-coding, up coding or missing modifiers causing denials, thereby dooming the revenue in-flow.
The key areas that we may need to focus in regards to getting paid for critical care services are:
Time:It is highly imperative that the duration of the medical service that was provided by the physician is documented. This is the amount of time the physician spent to cater to the critically ill patient in terms evaluating, managing and providing care.
Clinical Interventions: It is equally crucial to document the clinical intervention provided by the physician.
However, there are circumstances where the documentation lacks information either about the possible interventions or the total time of critical care provided. In both the scenarios, the coders should be cognizant of the potentiality of the chart going for critical care instead of billing as is. The medical coders should proactively query the physician for additional documentation that might qualify the service to be billed for critical care.
It's a universal fact that most claims get denied due to incorrect linking of the diagnosis code to the service provided by the physician. Patient came to ED setting for repair of leg laceration however physician performed EKG which is not related to the trauma. The claim gets denied had the coder linked leg laceration to the EKG. It's crucial for the coder to thoroughly read the medical record to ensure proper diagnosis code is appended to the EKG performed. The physician would have documented in the physical examination that patient had complained of left arm pain, chest pain or any condition that would support the service performed (EKG).
The precision and proficiency of a medical coder lies in the fact how well the medical record documentation is comprehended and coded appropriately. Our organization is capacitated with a dedicated team, who are AHIMA and AAPC certified, committed to deliver the best output.
There are umpteen examples to cite where the provider has lost revenue due to incorrect usage of modifiers. When physician performs multiple procedures due to unrelated conditions, the coder needs to be aware of the usage of right modifiers in order to get the claim paid appropriately on time. The claims often get denied due to the incorrect and random usage of most commonly used modifiers like 25, XU,XS,XP,XE, 51, etc.
Querying the provider
Many physicians do the hard work of providing extensive care to the critically ill-patients however miss to document the time thereby losing revenue for the service rendered. Our ED experts are adept in addressing such concerns by querying the provider for any additional documentation that might warrant for critical care.
Clinical Documentation improvement
Based on our experience with most free-standing or hospital based emergency departments, the precision of documentation in the medical records are suboptimal. The providers may not be aware of essential points to be included in the documentation to avoid delayed reimbursements. Our team puts in extra effort to assist the providers in clinical documentation improvement.
Compliance with the payer guidelines
Many a times, the denials are caused due to knowledge gap of the coders in deciding on the medical-decision making that may cause the claim to be either up-coded or down-coded delaying the reimbursement. The insurance levy heavy penalties for the providers for the malpractice or might even seize the provider from continuing the service. In any of the above circumstances, the provider is held responsible while they are not directly responsible. Our team can help you prevent getting into such risks with their quality coding ensuring we are compliant with the payer guidelines.