An 85 percent increase per member in emergency department spending between 2009 and 2015 was the result of hospitals coding and billing for a greater number of high severity cases, according to a 2017 Health Care Cost Institute (HCCI) study.
In the analysis of more than 70 million emergency department bills, the number of 99295s increased by 20 percent and 99284s by 10 percent, resulting in more than a 100 percent increase of spending. With overall emergency use remaining stagnant during the period, as expected the percentage of codes reflecting lower acuity cases dropped, with 37 percent fewer 99281s, 30 percent fewer 99282s, and 11 percent fewer 99283s.
But what does this upward shift in evaluation and management levels say about what’s happening in the ED?
Payers’ Perspective: Provider Upcoding?
Payers increasingly claim that the shift is a result of improper coding, or “upcoding,” where the code chosen is higher than the patient’s condition actually reflects. In March 2018, UnitedHealthcare began using their Optum Emergency Department Claim (EDC) Analyzer tool to evaluate facility ED claims and then deny or reduce payment for services they deem to be incorrectly coded.
Anthem also has implemented contentious policies in several states where emergency department claims are denied in cases where conditions are deemed “not emergencies” by the payer. According to Jenny Deam, in a recent Houston Chronicle article, these policies are intended “not only discourage inappropriate use of emergency rooms for non-emergency care but to also fight back against what it calls overtreatment and overbilling, including the practice of ‘up-coding’ where the highest level of severity code is used for less serious patients.”
Physicians Perspective: Sicker Patients?
Physicians and hospitals, however, have a different perspective: What if the higher level of coding isn’t a sign of a systemic money-grab by providers and instead reflects an evolving healthcare climate?
For instance, BMJ Open published a 2018 study of traditional Medicare claims from 2006, 2009 and 2012 where researchers documented an increase in services performed in the ED for patients with higher levels of service. They also found that, while in general, admissions from the ED went down, there was an increase in the number of patients admitted to the ICU from the ED. Those two factors could account, at least in part, for the increase in upper level coding, the authors concluded.
This would also reflect what many hospitals and physicians have been saying for years, that patients coming into the ED are older, have more chronic health conditions and comorbidities, and in general, are just sicker.
As early as 2012, the American Hospital Association published a TrendWatch report, revealing that “Medicare patients exhibit a growing prevalence of chronic conditions and risk factors for these conditions, such as obesity. This in turn is leading to a rise in Medicare beneficiaries use of health care services and has implications for resource use and payment policy.”
Finally, the increased percentage of higher levels of service in the ED may also be the result of another trend highlighted by a JAMA study back in September 2018: “More patients are choosing to treat low-acuity conditions in lower-cost urgent care centers and retail clinics, decreasing demand for emergency department services.” As alternate places of service siphon off lower acuity patients, a higher proportion of higher acuity patients would only make sense.
Unfortunately, that may mean policies like the ones Anthem and United Healthcare have rolled out recently may be punishing patients for making the exact choices the payers are trying to encourage, not to mention penalizing doctors for providing the kind of care sick patients really need.
True, the costs of emergency care are rising, along with the number of higher level patients, but the solution is not to keep sick people out of the ED or to blame physicians and hospitals for treating them.
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