Emergency Services

Session Goals

1. Why Focus on Your Emergency Department.Review Emergency Department Trends.

2. Proper Emergency Department E&M Levels.3. Establishing meaningful leveling methodology to capture

resources.4. Appropriate clinical supporting documentation for levels and

critical care.5. E.D. Patient Discharge Process

Point of Service CollectionsService Recovery

Why Focus On Your Emergency Department?

Front Door To The Health Care System

Why Focus On Your Emergency Department?

• Major Feeder to the hospital. – Greatest Source of Admissions. – 40-80% of Inpatient and Observation patients come from the ED

• Easy way to compete with less efficient hospitals• Improves Market Share: Extraordinary Patient Focused Care

• Reasons for ED Overcrowding– Baby Boomers coming of Medicare age– 7% decrease in number of ED’s with a 32% increase

in ED Visits the last 10 years.– PCP shortage: National Problem, Generational

Differences– Health care reform: Uninsured Insured,

Increase in ED Visits for primary care.– Safety Issues

Why Focus On Your Emergency Department?

Crowded emergency departments linked to more deaths, costs

Patients admitted during high ED crowding have 5% greater risk of dying December 6, 2012 | By Alicia Caramenico

High emergency department crowding is associated with increased inpatient mortality, as well as moderate rises in length of stay and costs, concludes a new study in the Annals of Emergency Medicine.

Patients admitted to the hospital during high ED crowding times had 5 percent greater risk of inpatient death than similar patients admitted to the same hospital when the ED was less crowded.

The researchers looked at almost 1 million ED visits resulting in admission to 187 hospitals and used daily ambulance diversion to measure ED crowding, according to a research announcement today.

They found that on days with a median of seven ambulance diversion hours, admitted patients had a 0.8 percent longer hospital length of stay and 1 percent higher costs.

Crowded emergency departments linked to more deaths, costs

Moreover, high ED crowding was associated with 300 excess inpatient deaths, 6,200 hospital days and $17 million in costs, the study noted.

Such findings are even more worrisome, given that half of health leaders say their ERs are overcrowded as is. Overcrowding is growing twice as fast as ER visits.

Hospitals looking to make their EDs less crowded should target Medicare patients, as almost 60 percent of their ER visits were "potentially preventable."

However, contrary to popular belief, nonurgent, Medicaid patients aren't clogging up the ED. Most Medicaid ED patients go because they have to, seeking emergent care for serious medical problems. Instead, most crowding stems from ED boarding, in which emergency patients admitted to the hospital are waiting for an inpatient bed, FierceHealthcare previously reported.

Researchers say the new study reinforces calls to end ED boarding. "Prolonged boarding times may delay definitive testing and increase short-term mortality, length of stay, and associated costs," the study states

Overcrowding and Pain Management

• Annual ED visits have increased in the past 10 years from 90.3 to 119.2 million (32% increase). With the new healthcare bill it is expected that the average ED will have increased volume of 6,500 patient visits.

• Number of ED’s have decreased 4019 to 3833, a 7% loss.

• Less ED’s and more ED visits have resulted in ED overcrowding.

• Pain has been deemed the “fifth vital sign” that should be routinely monitored. It is one of the leading complaints for patients in the emergency department. Knox, T. MD, MPH, Medscape Emergency Medicine. 2009 Mount Sinai School of Medicine reported a study of ED overcrowding and pain management.

• The authors showed at peak census, that on average, patients waited 55 minutes longer for pain assessments and 43 minutes longer to receive analgesics. Hwang, U. Acad. Emergency Medicine 2008; 15: 1248 –1255

• CMS will monitor throughput beginning in 2011 and pay hospitals for performance.

Centers for Medicare & Medicaid Services pilot program started 1st Qtr 2011

74 hospitals were the first to volunteer their data and show wide variation across the country.

Reporting for all hospitals, based on a 2% pay-for-performance incentive, began Jan. 1, 2012

National Quality Forum-approved benchmarks for emergency care

Health Leaders Media, May 7, 2012

• The number of minutes between the time the patient arrives at the ED to the time they depart the premises of the ED to be admitted to the hospital. (ED-1)

• The time between the moment a decision is made by the ED physician to admit the patient to a hospital bed to the time the patient departs the ED and is actually placed in an inpatient bed, a period sometimes referred to as "boarding.“ (ED-2)

• Starting January 1, 2012 a third wait time measure (ED-3) for patients treated and released.

Health Leaders Media, July 28, 2011

National Quality Forum-approved benchmarks for emergency care

ED-1 Measurement: Arrival to admission time on the floor

• Niagara Falls Memorial Hospital, Niagara Falls, NY 387 minutes

• Memorial Hermann Baptist Hospital, Orange, TX 358 minutes

• Perry Memorial Hospital in Perry, OK 52 minutes

• Paynesville Area Hospital, Paynesville, MN 90 minutes

Health Leaders Media, May 7, 2012

ED-2 Measurement: ED Physician decision time to admit

to admission time on the floor

• Memorial Hermann Baptist Hospital in Beaumont, TX 170 minutes

• Niagara Falls Memorial Hospital, Niagara Falls, NY 170 minutes

• Frio Regional Hospital, Pearsall, TX 0 minutes

• Pocahontas Memorial Hospital, Buckeye, WV 0 minutes

Health Leaders Media, May 7, 2012

Medical Screening Exam

GOALS:

Patient sign-in starts clock on the patient flow process.

Greet patients as they enter the ED.Implement initial time goals:

• arrival to start of MSE – 5 min.• arrival to disposition – 60 min average• arrival to admission / transfer – 90 min. average

Customer Satisfaction

0 to 30 31 to 60 60 to 90 90 +3.2

3.4

3.6

3.8

4

4.2

4.4

4.6

Average Patient Satisfaction by Time to Provider Interval

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Time to Provider Interval

The amount of time spent in the ED is a critical factor in the overall satisfaction of ED patients. The following graph shows that satisfaction declines dramatically after two hours and continues to fall with each additional hour.

Represents the experiences of 1,524,726 patients treated at 1,656 EDs nationwide between January 1 and December 31, 2007. Emergency Department Pulse Report

© 2008 by Press Ganey Associates, Inc.

0 to 1 1 to 2 2 to 3 3 to 4 4 to 5 5 to 6 6 >65%

70%

75%

80%

85%

90%

95%

Patient Satisfaction by Time Spent in ED

Hours

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The More Time Spent in the Emergency DepartmentThe Less Satisfied the Patient

Lost Revenue compared to % LWBS

$-

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

$700,000

$800,000

$900,000

Hospital X: % LWBS and Lost Net Revenue

8% 6% 4% 2%

Industry

7AM - 3PM 3PM - 11PM 11PM - 7AM

84.3

82.1

82.8

Time of Day Arrived

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Satisfaction with the Emergency Department by Time of Day Arrived

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

0.5

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1.5

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4.5

ED Patients by Hour of DayIN-Patient admissions by hour of dayIn-Patient Discharges by hour of day

Hospital activity by hour of day

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

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ED Patients by Hour of DayIN-Patient admissions by hour of dayIn-Patient Discharges by hour of day

Peak In-Patient Discharge time

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

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ED Patients by Hour of DayIN-Patient admissions by hour of dayIn-Patient Discharges by hour of day

Peak In-Patient Admission Time

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

0.5

1

1.5

2

2.5

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3.5

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ED Patients by Hour of DayIN-Patient admissions by hour of dayIn-Patient Discharges by hour of day

Peak In-Patient Admission and Discharge Time

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

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1.5

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ED Visits by hour of dayIn-patient admissions by hour of dayIn -patient discharges by hour of day

What would happen if we moved discharges 2 hours earlier?

NEDOCS

• National Emergency Department Overcrowding Scale

• Full Capacity Protocols

MODEL SPECIFIC

Total Admits in the ED

Waiting room wait time for last patient called

(In hours)

NEDOCS SCORE-

Clear Fields

INSTITUTIONAL CONSTANTS

Number of ED Beds

Number of Hospital Beds

COMMON ELEMENTS

Total Patients in the ED

Number of Respirators in the ED

Longest admit time (in hours)

http://hsc.unm.edu/emermed/nedocs_fin.shtml

NEDOCS

• Develop Full Capacity Protocol Work Group of department heads and staff.• Incorporate NEDOCS into your protocol• Include Clinical and Non-Clinical areas into your protocol• Consider Incident Command as part of your protocol

00 to 20 Not busy

21 to 60 Busy

61 to 100 Extremely busy

but not overcrowded

101 to 140 Over-crowded

141 to 180 Severely

over-crowded

181 to 200-Dangerously over-crowded

CHARGES

Effective charge captures process

ED CHARGES

• Hospitals have traditionally viewed ED’s as cost centers• ED margin management typically means reducing cost,

often through painful staff reductions. • Hospitals can have multi-million dollar impact on their ED

margins by aggressively managing top-line revenues through optimized facility evaluation and management (E/M) charges and point-of-service (POS) cash collection.

Advisory Board

ED CHARGES

Level 1-3; 25%

Level 4; 37%

Level 5; 39%

Inconsistent ED Coding RampantE/M codes for patients with CT Scans

n=17 hospitals

Source: Advisory Board

ED CHARGES

• Documentation is key to the E/M charging process• ED Directors typically do not manage the E&M charge process well.• REASONS:

– Lack of tools and information– Poor communications with coders and HIM– Poor communication or access with the business office to ensure charges are

optimized.

ED management needs easy access to financial information and collaboration across functional silos to be able to improve financial performance in the ED.

Advisory Board

E&M Leveling

• There are no national guidelines for hospital out-patient and emergency department E&M (Evaluation & Management) coding to date.

• CMS has stated that each hospital must create their own guidelines.

• These guidelines should reasonably relate to the resources expended related to the intensity of the patient’s condition.

• The following is the minimal criteria for E&M leveling from CMS:

CMS E&M Criteria • Follow the intent of the CPT code descriptor in that the guidelines should be designed to

reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.

• Be based on hospital facility resources and not on physician resources.• Be clear to facilitate accurate payments and be usable for compliance purposes and audits• Meet HIPPA requirements• Only require documentation that is clinically necessary for patient care• Do not facilitate up-coding or gaming• Be written or recorded, well documented, and provide the basis for selection of a specific

code.• Be applied consistently across patients in the clinic or ED to which they apply.• Not change with frequency• Be readily available for FI (or, if applicable, Medicare administrator contractor [MAC]

review)• Result in coding decisions that could be verified by other hospital staff, as well as outside

sources.• (Source: Federal Register, Vol. 72, No.227, p66805)

E&M Leveling

Types of E&M Leveling based on:• Diagnosis • Time• Point System• Procedures

Or

A combination of some or all

E&M Leveling

Key Elements to Maximizing E&M Leveling and Charges:• Develop, purchase or “Borrow” an effective leveling tool• Develop a concurrent chart review system before staff go

home.• Create a communication system between the HIM coder and

the physician or nursing staff.• Log and monitor the HIM communications with ED Staff• Continually educate and remind staff regarding effective

documentation.

E&M Leveling

Note from the coder

Date:___________A Note from the Coder: Please provide the following:

Dictation T-SheetDiagnosisMedical Decision MakingROS FSHHPI DispositionSignatureTime of Exam Needed:Laceration Length Physician’s Order Sheet IV Start/Stop time Critical Care TimePain Assessment Vital Sign Sheet

Physician Order for___________________________________________________ MISC:_____________________________________________________________ Please return chart to ER clerical desk for re-scanning and then to be returned to ___________(name)

E&M Leveling

LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 LEVEL 60%

5%

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20%

25%

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50%

Rev & Usage Report

Goals

Charge Master

• CDM could have approximately 450 line items for procedures

• Avoid low, moderate, complex bundled charges• Be sure that bundled procedure charges exceed

Medicare Fee schedule

Documentation

Documentation

Communicates to other caregivers what was done

Facilitates patient care

Supports data collection

Reflects quality of decision making

Justifies legal defense

Supports regulatory compliance

Supports fair payment / reimbursement

Sound professional practice !

Why is documentation so important?

ED physician and nursing documentation in some cases is weak or missing. The documentation does not fully support patient care, correct coding and accurate charging.

Examples:- Length of laceration is not always documented.- IV start and stop time is often not documented.- Critical care nursing time is not documented.- Physicians’ charts are not always complete.- Documentation does not always comply with payer and

regulatory guidelines.- In most cases, provided care supported higher facility E&M

levels.

Physician and NursingDocumentation

Documenting Critical Care

Documentation

Critical care defines the basis for emergency medicine, yet it is the most under reported service we do!

Definition of Critical Care CPT 99291

Documentation

“Critical care is the direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.

Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present. *

CMS TRANSMITTAL 1548 JULY 9, 2008 http://www.cms.hhs.gov/Transmittals/Downloads/R1548CP.pdf

Critical Care Services Physician Time

Documentation

• The CPT critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous.

• Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician (§30.6.5).

For CY 2011, the AMA CPT Editorial Panel is revising its guidance for the critical care codes to specifically state that, for hospital reporting purposes, critical care codes do not include the specified ancillary services.

Beginning in CY 2011, hospitals that report in accordance with the CPT guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care.

Reference: Federal Register / Vol. 75, No. 226 / Wednesday, November 24, 2010 / Rules and Regulations Pg. 71988

Documentation

Documenting Critical Care

We refer readers to the July 2008 OPPS quarterly update, Transmittal 1536, Change Request 6094, issued on June 19, 2008, for further clarification about the reporting of CPT codes for hospital outpatient services paid under the OPPS. In that transmittal, we note that while CPT codes generally are created to describe and report physician services, they are also used by other providers/suppliers to describe and report services that they provide. Therefore, the CPT code descriptors do not necessarily reflect the facility component of a service furnished by the hospital. Some CPT code descriptors include reference to a physician performing a service. For OPPS purposes, unless indicated otherwise, the usage of the term "physician" does not restrict the reporting of the code or application of related policies to physicians only, but applies to all practitioners, hospitals, providers, or suppliers eligible to bill the relevant CPT codes pursuant to applicable portions of the Act, the CFR, and the Medicare rules . In cases where there are separate codes for the technical component, professional component, and/or complete procedure, hospitals should report the code that represents the technical component for their facility services. If there is no separate technical component code for the service, hospitals should report the code that represents the complete procedure. Consistent with past input we have received from many hospitals, hospital associations, the APC Panel, and others, we will continue to utilize CPT codes for reporting services under the OPPS whenever possible to minimize hospitals’ reporting burden. If the AMA were to create facility-specific CPT codes for reporting visits provided in HOPDs, we would certainly consider such codes for OPPS use.

CMS-1404-FC-CMS-3887-F-CMS-3835-F1 Pg 741 - 742

Critical Care Billing

Documentation

From 1996 to 1999, 1.3% of all ER visits across the nation were billed as Critical Care.

In 2000, 1.8% of all ER visits were billed as Critical Care.

Real Life Scenarios — Current research shows that at least 5% to 7% of all ER visits should

qualify for Critical Care billing. In 2009 the ED billed <1% Critical Care.

CMS mandated that critical care nursing time be documented beginning January 1, 2007. January 1, 2009 requires nursing to document additional 30 minutes of time (99292).

Key indicators for documenting Critical Care

Documentation

Consider the following interventions as typical ofpatients that require critical care:

Airway Monitoring CPRAny continuous monitoring IntubationCentral line placement Physical & Chemical RestraintsChest tube insertion Titration of dripsCODE STEMI protocol Patients that goes to the OR

on an emergent basis

Emergency Department Patient Discharge Process

• Point of Service Collections• Collecting Past Open Balances• Service Recovery

GOALS:

Nursing to escort all ED patients to discharge desk. Establish a goal of $25 to be collected per discharged patient. This will increase revenue dramatically and decrease collection costs. Utilize discharge process to perform financial counseling. Re-check accuracy of registration. Service reconciliation.

Disposition POSC

Service Recovery

• If Service recovery is needed (poor-to-fair care). “Thank you for your concerns, I apologize. I will follow up with our manager.”

• “Would you like our manager, name, to call you back?”

• “Mr. / Mrs. _____________ (name of patient), a last question for you: Are there any individuals whom you would like me to compliment for the care they provided? I would be happy to take their names.”

• Peer to Peer Recognition with this question.

Recognition of Staff

Final Statement to Patient

“You may be receiving a survey phone call. We appreciate you taking the time to answer the

survey questions as your feedback helps us to improve our care. Thank you for choosing Regional Hospital to meet your healthcare

needs.”

Dashboard

Financial• Charges to budget• Cost to budget• Materials Management shrinkage• Pharmacy shrinkage• Level statistics

– Facility– Physician

• Amount collected at time of discharge• Accuracy of registration

Operations

• Door to triage time• Door to Doc time• Door to discharge time• Door to admit time• Doctors order to admit time• Average Radiology order to film availability time by top 10 procedures• Average Radiology order to report time• Average Laboratory order time to results reported by top 10 procedures• Monthly volume

– Total– Treat and release– Treat and admit– Treat and transfer

•

Dashboard

Quality• Physician Peer review• Patients who return within 72 hours• Number of charts returned to staff• Number of charts down coded• Quality issues from CMS-Core Measures• Hemolysis rate• Level of cleanliness in ED• Incomplete chart rate

– Facility– Physicians

Dashboard

Patient Satisfaction• Press Ganey quarterly report• AMA• LWBS• Patient complaints• Results from patient survey• Physician complaints• Nursing complaints

Dashboard

Thank You