March 7—Medicare emergency department (ED) patients have gotten sicker in recent years, according to a new analysis of hospital coding trends. As a result, national ED coding guidelines may be needed, said the congressional advisory panel that conducted the analysis.
The not -yet-published analysis by the staff of the Medicare Payment Advisory Commission (MedPAC) found the distribution of coding for Medicare patients’ ED visits changed from a fairly even pattern across the five levels of intensity in 2005 to a concentration in the three highest levels in 2017.
However, the coding change did not accompany any change in the principal diagnoses on the claims or a significant change in the reasons given for seeking care, according to the analysis.
Additional findings showed large differences based on geographic area in both coding and how the coding changed from 2005 to 2017.
Hospital advocates questioned whether the changes in coding patterns stemmed from sicker Medicare ED patients and improving medical technology, which would be more likely to be deployed for sicker patients.
However, MedPAC’s data rejected one popular theory: that lower-acuity Medicare patients have been siphoned off by urgent care centers (UCCs), which would leave sicker patients, on average, at EDs. The group found no correlation between ED coding changes and UCC use.
Nonhospital analysts previously have attributed the increasing intensity of hospital coding to reasons ranging from hospitals taking advantage of coding rules to hospitals providing more care.
“I think a lot of folks were certainly surprised by some of these things,” Jonathan Jaffery, MD, a MedPAC commissioner and professor of medicine at the University of Wisconsin School of Medicine and Public Health.
MedPAC members were surprised that even though the American Hospital Association and the American College of Emergency Physicians developed ED coding guidelines, most hospitals appeared to follow their own rules.
In response, MedPAC is considering a recommendation that the U.S. Department of Health and Human Services (HHS) develop and implement a set of “national guidelines” for coding hospital ED visits under the Outpatient Prospective Payment System by 2022.
To determine the coding level, approaches could focus on the number of interventions, implement some type of scoring for various interventions, or consider staff time and patient complexity. Previously, the Centers for Medicare & Medicaid Services (CMS) has favored a coding approach based on staff clinical interventions.
Such guidelines aim to ensure that payments accurately reflect the amount of hospital resources used during an ED visit, provide clear rules for coding ED visits, and provide the CMS with clear grounds for assessing and auditing coding behavior.
Published research has linked greater use of EDs to an ED’s ease as a point of access, its appeal to lower-income patients, and a lack of knowledge of other healthcare access points.
Service Intensity
Another finding of MedPAC staff was that from 2011 to 2016 hospitals increased the number of services provided during ED visits—especially CTs and EKGs. There was little change in the volume of lab tests or procedures.
The analysis also found that EKGs have become common for chest pain and CTs for head injuries.
Some commissioners theorized that some combination of upcoding and increasing liability concerns may have driven increased precautionary use of scans, or that the adoption of electronic health records could have contributed to the more intense utilization or greater efficiency could allow them to treat more patients.
Jonathan Perlin, MD, PhD, a MedPAC commissioner and president of clinical services and chief medical officer for HCA Healthcare in Nashville, noted that coding intensity increased during implementation of the two-midnight rule governing low-acuity admissions. As a result, many hospitals did not admit patients to avoid running afoul of auditors and instead kept patients in the ED whom they might have previously admitted.
“It doesn’t strike me that the changes in coding drove it,” Perlin said.
The staff was perplexed by their finding that EKGs and CTs of the head have become “fairly common” in cases of urinary tract infection.
One commissioner said the finding could stem from instances when elderly Medicare patients arrive at the ED confused, possibly leading physicians to recommend that they be scanned for signs of stroke, then secondarily suspecting UTI. Such infections commonly lead to symptoms of confusion in that population.
Nonurgent Care
Medicare beneficiaries made 1.5 million visits to EDs for nonurgent conditions in 2017, according to MedPAC staff. The finding followed previous MedPAC concerns about the increase in Medicare ED spending.
The MedPAC staff acknowledged that in some markets increases in ED use were driven by lack of access to alternative care settings, like UCCs or physician offices.
Monday, March 11
Deadline for members of the pharmaceutical distribution supply chain to apply to participate in a Food and Drug Administration pilot to test an enhanced electronic, interoperable track-and-trace system. Learn more.
National Physician Advisor Conference in Atlanta (through March 13). Learn more.
American Hospital Association (AHA) webinar titled “Zeroing in on ZIP Codes to Improve Employee Health.” Learn more.
Tuesday, March 12
CMS webinar titled “Hospital VBP Program, HAC Reduction Program, and Hospital Readmissions Reduction Program FY 2019 Hospital Compare Data Update.” Learn more.
CMS webcast titled “Dementia Care & Psychotropic Medication Tracking Tool Call.” Learn more.
AHA webinar titled “Prescribe Safe Initiative: Combatting Opioid Abuse.” Learn more.
American Academy of Orthopedic Surgeons Annual Meeting in Las Vegas (through March 16). Learn more.
Medical Group Management Association webinar titled “Maximize Bundled Payment Financial Results.” Learn more.
House Energy & Commerce Committee Health Subcommittee hearing titled “The Fiscal Year 2020 HHS Budget.” Learn more.
House Oversight and Government Reform Committee hearing titled “Examining the Public Health Risks of Carcinogens in Consumer Products.” Learn more
Wednesday, March 13
Nextgov’s “Healthcare 2030” Forum in Washington, D.C. Learn more.
House Energy & Commerce Committee Health Subcommittee hearing titled “Lowering the Cost of Prescription Drugs: Reducing Barriers to Market Competition.” Learn more.
CMS webcast titled “Open Payments: Transparency and You.” Learn more.
AHA webinar titled “Patient Satisfaction: The Laboratory’s Role in Caring for and Serving Patients.” Learn more.
CMS National Provider Enrollment Conference in Nashville. Learn more.
America’s Health Insurance Plans’ (AHIP’s) National Health Policy Conference in Washington D.C. (through March 14). Learn more.
20th Annual Emerging Issues in Healthcare Law Conference in Orlando (through March 16).Learn more.
Thursday, March 14
Deadline for registration and attestation submission under the Promoting Interoperability Programs. Learn more.
AHIP’s National Conference on the Individual and Small Group Markets in Washington, D.C. (through March 15). Learn more.
AHA webinar titled “Intersection of Human Trafficking and the Opioid Crisis.” Learn more.
Friday, March 15
Deadline for start-up companies to apply for the HFMA Annual Conference Virtual Pitch Contest. Learn more.
Livestream of congressional briefing by the National Coalition on Health Care to discuss the use of binding arbitration in pricing of prescription drugs. Learn more.
Deadline to respond to a request for information from the National Science Foundation on helping medical devices and data platforms to be interoperable, and federal interoperability goals. Learn more.
