ACEP Reimbursement & Coding Conference

SAN DIEGO – Adding hospitalist services is perhaps the most challenging of all the additional revenue opportunities for ED revenue stream expansion and diversification.

Part of the challenge is the differences in Relative Value Units (RVUs) between initial hospital care (CPT codes 99221-223) and subsequent hospital care (CPT codes 99231-33), Dr. Michael A. Granovsky said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

"If you have a 3-day hospital stay, you have 1 day of initial care and 2 days of subsequent care, and there’s a huge revenue difference," explained Dr. Granovsky, a reimbursement and coding expert who is president of Bedford, Mass.–based LogixHealth. For example, the 2013 CMS payment for CPT code 99221 (low-severity care provided within 30 minutes) is $99.34, compared with $38.11 for CPT code 99231 (patient is stable or recovering and the encounter takes 15 minutes or less). "When looking at a pro forma for a hospital medicine group [you want to know] what the length of stay is," said Dr Granovsky, who is also the editor of "ED Coding Alert."

Hospitalists are often called upon to provide a vast array of services, including providing critical care (CPT code 99291), putting in a central line (CPT code 36556), performing CPR (CPT code 92950), and intubation (CPT code 31500). Basic costs to setting up a hospitalist service include salary, benefits, malpractice insurance, and billing. "The hospitalists need some meaningful practice infrastructure in place as well," Dr. Granovsky noted. "Hospitalists need management or clerical support. With a little education it’s probably a good idea for the hospitalists to fill out a charge ticket for coding."

The main advantage to providing hospitalist services is to "further cement the relationship within the hospital and protect your ED contract," he said. "This can help you streamline and control the admission process."

Fully fee-for-service hospitalist groups frequently require a stipend and the typical payer might be 55% Medicare, 10% Medicaid, 12% commercial insurance, 13% Blue Cross Blue Shield, and 10% self-responsible. Hospitalists turn over an average of 60 patients per week, "which generates about $70,000/month in revenue, which would be equal to $840,000 in 1 year," Dr. Granovsky said. "However, it can cost as much as $970,000 in salary and benefits for six full-time physicians to cover services 24 hours per day. Add in vacations, billing services, malpractice insurance and other services, and you have a big gap between the $840,000 that comes in and the $970,000, which is the cost for just putting the providers in place. As a result, typical hospitalist services require a stipend of several hundred thousand dollars just to break even."

Other ED revenue stream expansion and diversification opportunities he discussed include the following:

• Urgent care centers. Dr. Granovsky characterized this as a volume-driven business that requires 22-25 patients/day for the provider to break even. The first step is choosing the right location for the center "because you are volume dependent, and the volume is dependent on foot traffic," he said. "A new urgent care center could compete with your ED Fast Track if it’s too close by. Don’t risk your own money for a de novo site based on a consultant’s estimate of potential patient volumes. I would be very conservative [in estimating your market potential] when it comes to patient volumes. Not only is your general location important, but you also need easy patient access and convenient parking. I have not seen one significantly successful urgent care clinic that was not on the first floor."

Urgent care centers fall into one of three place of service (POS) designations: POS 20 is described as an office or clinic other than an ED for unscheduled, ambulatory patients seeking immediate attention. POS 22 is an outpatient hospital clinic that is typically on the hospital’s cost report and POS 11 is a nonhospital setting where routine care such as health exams, diagnosis, and treatment is provided on an ambulatory basis.

Clinicians who practice in POS 20, POS 22, and POS 11 settings typically report the office/other outpatient codes 99201-99205 for new patients and 99211-99215 for established patients. "There is a 25%-30% decrease in reimbursement for the same ankle sprain, sore throat, or otitis media when you see them the second time as an established patient," said Dr. Granovsky, who chairs ACEP’s Coding and Nomenclature Committee. "So whenever you look at a pro forma and run financials for an urgent care center, you have to assume that your per-patient revenue is going to decrease over time because your case mix over time will move predominately to established patients."

Total urgent care start-up costs range from $600,000 to $800,000. Ongoing expenses include rent, personnel, practice management, legal accounting insurance, billing, equipment and maintenance. "Providing higher-acuity services – Level 3 and Level 4 ER services seems to be the trend right now," he said. "A typical site may generate $100-$120/visit."

The general recipe for success is to have 25 patient visits per day, which translates into about 600 patient visits per month, or $60,000/month in revenue. "Some combination of patient revenue based on your contracted rate and volume needs to exceed your fixed cost," Dr. Granovsky said. "Good payer contracts are key. Before you spend a lot of money to open an urgent care clinic, do a little research to find out what your contracted rates will be. If those rates are poor, you’ll never make your money back. Partnering with a hospital is a conservative way to do it."

• Freestanding EDs. These facilities are typically owned and operated by a hospital or by a group of emergency medicine physicians. The business model can be profitable but many states require a Certificate of Need (CON) process in order to open one. "Unless you are a hospital it’s very hard to get through the CON regulatory process," Dr. Granovsky emphasized. "It’s expensive, daunting, and the cards are stacked against you. But some states, including Texas, Arizona, and Colorado, don’t require a CON. That’s one of the reasons why freestanding emergency departments owned by entrepreneurial physicians have prospered in those states."

Freestanding EDs can perform pretty much all the essential functions of a hospital-based ED except admit patients. As in the case of urgent care centers, location determines your payer mix. They may or may not participate with Medicare and Medicaid. Some freestanding centers can break even with as few as 12 patients per day.

"A single patient can potentially generate more than $500, even more if the patient requires sophisticated ancillary testing," he said. "You typically need to have a couple of million dollars to get started. Large ED groups are typically ones pursuing this, or you need investor partnering."

Dr. Granovsky said that he had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Adding hospitalist services is perhaps the most challenging of all the additional revenue opportunities for ED revenue stream expansion and diversification.

Part of the challenge is the differences in Relative Value Units (RVUs) between initial hospital care (CPT codes 99221-223) and subsequent hospital care (CPT codes 99231-33), Dr. Michael A. Granovsky said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

"If you have a 3-day hospital stay, you have 1 day of initial care and 2 days of subsequent care, and there’s a huge revenue difference," explained Dr. Granovsky, a reimbursement and coding expert who is president of Bedford, Mass.–based LogixHealth. For example, the 2013 CMS payment for CPT code 99221 (low-severity care provided within 30 minutes) is $99.34, compared with $38.11 for CPT code 99231 (patient is stable or recovering and the encounter takes 15 minutes or less). "When looking at a pro forma for a hospital medicine group [you want to know] what the length of stay is," said Dr Granovsky, who is also the editor of "ED Coding Alert."

Hospitalists are often called upon to provide a vast array of services, including providing critical care (CPT code 99291), putting in a central line (CPT code 36556), performing CPR (CPT code 92950), and intubation (CPT code 31500). Basic costs to setting up a hospitalist service include salary, benefits, malpractice insurance, and billing. "The hospitalists need some meaningful practice infrastructure in place as well," Dr. Granovsky noted. "Hospitalists need management or clerical support. With a little education it’s probably a good idea for the hospitalists to fill out a charge ticket for coding."

The main advantage to providing hospitalist services is to "further cement the relationship within the hospital and protect your ED contract," he said. "This can help you streamline and control the admission process."

Fully fee-for-service hospitalist groups frequently require a stipend and the typical payer might be 55% Medicare, 10% Medicaid, 12% commercial insurance, 13% Blue Cross Blue Shield, and 10% self-responsible. Hospitalists turn over an average of 60 patients per week, "which generates about $70,000/month in revenue, which would be equal to $840,000 in 1 year," Dr. Granovsky said. "However, it can cost as much as $970,000 in salary and benefits for six full-time physicians to cover services 24 hours per day. Add in vacations, billing services, malpractice insurance and other services, and you have a big gap between the $840,000 that comes in and the $970,000, which is the cost for just putting the providers in place. As a result, typical hospitalist services require a stipend of several hundred thousand dollars just to break even."

Other ED revenue stream expansion and diversification opportunities he discussed include the following:

• Urgent care centers. Dr. Granovsky characterized this as a volume-driven business that requires 22-25 patients/day for the provider to break even. The first step is choosing the right location for the center "because you are volume dependent, and the volume is dependent on foot traffic," he said. "A new urgent care center could compete with your ED Fast Track if it’s too close by. Don’t risk your own money for a de novo site based on a consultant’s estimate of potential patient volumes. I would be very conservative [in estimating your market potential] when it comes to patient volumes. Not only is your general location important, but you also need easy patient access and convenient parking. I have not seen one significantly successful urgent care clinic that was not on the first floor."

Urgent care centers fall into one of three place of service (POS) designations: POS 20 is described as an office or clinic other than an ED for unscheduled, ambulatory patients seeking immediate attention. POS 22 is an outpatient hospital clinic that is typically on the hospital’s cost report and POS 11 is a nonhospital setting where routine care such as health exams, diagnosis, and treatment is provided on an ambulatory basis.

Clinicians who practice in POS 20, POS 22, and POS 11 settings typically report the office/other outpatient codes 99201-99205 for new patients and 99211-99215 for established patients. "There is a 25%-30% decrease in reimbursement for the same ankle sprain, sore throat, or otitis media when you see them the second time as an established patient," said Dr. Granovsky, who chairs ACEP’s Coding and Nomenclature Committee. "So whenever you look at a pro forma and run financials for an urgent care center, you have to assume that your per-patient revenue is going to decrease over time because your case mix over time will move predominately to established patients."

Total urgent care start-up costs range from $600,000 to $800,000. Ongoing expenses include rent, personnel, practice management, legal accounting insurance, billing, equipment and maintenance. "Providing higher-acuity services – Level 3 and Level 4 ER services seems to be the trend right now," he said. "A typical site may generate $100-$120/visit."

The general recipe for success is to have 25 patient visits per day, which translates into about 600 patient visits per month, or $60,000/month in revenue. "Some combination of patient revenue based on your contracted rate and volume needs to exceed your fixed cost," Dr. Granovsky said. "Good payer contracts are key. Before you spend a lot of money to open an urgent care clinic, do a little research to find out what your contracted rates will be. If those rates are poor, you’ll never make your money back. Partnering with a hospital is a conservative way to do it."

• Freestanding EDs. These facilities are typically owned and operated by a hospital or by a group of emergency medicine physicians. The business model can be profitable but many states require a Certificate of Need (CON) process in order to open one. "Unless you are a hospital it’s very hard to get through the CON regulatory process," Dr. Granovsky emphasized. "It’s expensive, daunting, and the cards are stacked against you. But some states, including Texas, Arizona, and Colorado, don’t require a CON. That’s one of the reasons why freestanding emergency departments owned by entrepreneurial physicians have prospered in those states."

Freestanding EDs can perform pretty much all the essential functions of a hospital-based ED except admit patients. As in the case of urgent care centers, location determines your payer mix. They may or may not participate with Medicare and Medicaid. Some freestanding centers can break even with as few as 12 patients per day.

"A single patient can potentially generate more than $500, even more if the patient requires sophisticated ancillary testing," he said. "You typically need to have a couple of million dollars to get started. Large ED groups are typically ones pursuing this, or you need investor partnering."

Dr. Granovsky said that he had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Adding hospitalist services is perhaps the most challenging of all the additional revenue opportunities for ED revenue stream expansion and diversification.

Part of the challenge is the differences in Relative Value Units (RVUs) between initial hospital care (CPT codes 99221-223) and subsequent hospital care (CPT codes 99231-33), Dr. Michael A. Granovsky said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

"If you have a 3-day hospital stay, you have 1 day of initial care and 2 days of subsequent care, and there’s a huge revenue difference," explained Dr. Granovsky, a reimbursement and coding expert who is president of Bedford, Mass.–based LogixHealth. For example, the 2013 CMS payment for CPT code 99221 (low-severity care provided within 30 minutes) is $99.34, compared with $38.11 for CPT code 99231 (patient is stable or recovering and the encounter takes 15 minutes or less). "When looking at a pro forma for a hospital medicine group [you want to know] what the length of stay is," said Dr Granovsky, who is also the editor of "ED Coding Alert."

Hospitalists are often called upon to provide a vast array of services, including providing critical care (CPT code 99291), putting in a central line (CPT code 36556), performing CPR (CPT code 92950), and intubation (CPT code 31500). Basic costs to setting up a hospitalist service include salary, benefits, malpractice insurance, and billing. "The hospitalists need some meaningful practice infrastructure in place as well," Dr. Granovsky noted. "Hospitalists need management or clerical support. With a little education it’s probably a good idea for the hospitalists to fill out a charge ticket for coding."

The main advantage to providing hospitalist services is to "further cement the relationship within the hospital and protect your ED contract," he said. "This can help you streamline and control the admission process."

Fully fee-for-service hospitalist groups frequently require a stipend and the typical payer might be 55% Medicare, 10% Medicaid, 12% commercial insurance, 13% Blue Cross Blue Shield, and 10% self-responsible. Hospitalists turn over an average of 60 patients per week, "which generates about $70,000/month in revenue, which would be equal to $840,000 in 1 year," Dr. Granovsky said. "However, it can cost as much as $970,000 in salary and benefits for six full-time physicians to cover services 24 hours per day. Add in vacations, billing services, malpractice insurance and other services, and you have a big gap between the $840,000 that comes in and the $970,000, which is the cost for just putting the providers in place. As a result, typical hospitalist services require a stipend of several hundred thousand dollars just to break even."

Other ED revenue stream expansion and diversification opportunities he discussed include the following:

• Urgent care centers. Dr. Granovsky characterized this as a volume-driven business that requires 22-25 patients/day for the provider to break even. The first step is choosing the right location for the center "because you are volume dependent, and the volume is dependent on foot traffic," he said. "A new urgent care center could compete with your ED Fast Track if it’s too close by. Don’t risk your own money for a de novo site based on a consultant’s estimate of potential patient volumes. I would be very conservative [in estimating your market potential] when it comes to patient volumes. Not only is your general location important, but you also need easy patient access and convenient parking. I have not seen one significantly successful urgent care clinic that was not on the first floor."

Urgent care centers fall into one of three place of service (POS) designations: POS 20 is described as an office or clinic other than an ED for unscheduled, ambulatory patients seeking immediate attention. POS 22 is an outpatient hospital clinic that is typically on the hospital’s cost report and POS 11 is a nonhospital setting where routine care such as health exams, diagnosis, and treatment is provided on an ambulatory basis.

Clinicians who practice in POS 20, POS 22, and POS 11 settings typically report the office/other outpatient codes 99201-99205 for new patients and 99211-99215 for established patients. "There is a 25%-30% decrease in reimbursement for the same ankle sprain, sore throat, or otitis media when you see them the second time as an established patient," said Dr. Granovsky, who chairs ACEP’s Coding and Nomenclature Committee. "So whenever you look at a pro forma and run financials for an urgent care center, you have to assume that your per-patient revenue is going to decrease over time because your case mix over time will move predominately to established patients."

Total urgent care start-up costs range from $600,000 to $800,000. Ongoing expenses include rent, personnel, practice management, legal accounting insurance, billing, equipment and maintenance. "Providing higher-acuity services – Level 3 and Level 4 ER services seems to be the trend right now," he said. "A typical site may generate $100-$120/visit."

The general recipe for success is to have 25 patient visits per day, which translates into about 600 patient visits per month, or $60,000/month in revenue. "Some combination of patient revenue based on your contracted rate and volume needs to exceed your fixed cost," Dr. Granovsky said. "Good payer contracts are key. Before you spend a lot of money to open an urgent care clinic, do a little research to find out what your contracted rates will be. If those rates are poor, you’ll never make your money back. Partnering with a hospital is a conservative way to do it."

• Freestanding EDs. These facilities are typically owned and operated by a hospital or by a group of emergency medicine physicians. The business model can be profitable but many states require a Certificate of Need (CON) process in order to open one. "Unless you are a hospital it’s very hard to get through the CON regulatory process," Dr. Granovsky emphasized. "It’s expensive, daunting, and the cards are stacked against you. But some states, including Texas, Arizona, and Colorado, don’t require a CON. That’s one of the reasons why freestanding emergency departments owned by entrepreneurial physicians have prospered in those states."

Freestanding EDs can perform pretty much all the essential functions of a hospital-based ED except admit patients. As in the case of urgent care centers, location determines your payer mix. They may or may not participate with Medicare and Medicaid. Some freestanding centers can break even with as few as 12 patients per day.

"A single patient can potentially generate more than $500, even more if the patient requires sophisticated ancillary testing," he said. "You typically need to have a couple of million dollars to get started. Large ED groups are typically ones pursuing this, or you need investor partnering."

Dr. Granovsky said that he had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – In the opinion of Dr. Kirk B. Jensen, efforts to maximize patient throughput in the emergency medicine department are crucial.

A critical driver in patient satisfaction is how much time it takes for a patient to see a physician upon arrival. "I am not saying that the physician is the most important person in the equation in the emergency department, but from an operational standpoint the goal in your emergency department is to get the physician and the patient together as quickly as possible," Dr. Jensen said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

Patient satisfaction surveys are another driver. "We can quibble with the methodology of patient satisfaction surveys but they are clearly here [to stay] and they command our attention and measure our performance," said Dr. Jensen, chief medical officer at Raleigh, N.C.–based BestPractices, a division of EmCare, which provides ED management and staffing solutions. "Patient satisfaction declines as a function of time spent in the ED. The more time people spend with us, the less happy they are."

Another reason to pay attention to patient flow is the threat of malpractice. One review of wait times and claims per 25,000 patient visits at 36 emergency departments in California found that patients who waited more than 60 minutes to be seen were more than four times as likely to file a malpractice claim, compared with those who waited less than 30 minutes. "The longer it takes to see the physician, the more likely you are to get sued," said Dr. Jensen, who was not involved with the study. "There’s a direct, linear correlation. So when you want to get the attention of people on your ED team to rally around throughput and rally around improving productivity, you can always use data on malpractice and the risk of getting sued as a driver for changing behavior."

There is also a financial case for improving patient throughput in the ED. One ED in which Dr. Jensen assisted as a consultant had 40,000 patient visits per year and set out to reduce the average length of stay from 3 hours to 2 hours. "This generated 40,000 hours of new service delivery which meant a potential to see 20,000 more patients," he said. "If your average net revenue is $100 per patient and you can see 20,000 more patients, that creates $2 million in additional revenue for your physician practice and three to five times that for the hospital."

He advises clinicians to think about the path of an ED patient as having a beginning, a middle, and an end, and to look for ways to improve throughput at each juncture. In his experience, the points with the greatest leverage for throughput improvements are on the front end and at the back end. He described the front end as "the fly wheel that makes your ED hum. Focusing on those processes and that operation is critical to getting the kind of patient flow and throughput that you want. There are also opportunities on the back end, especially for those of us who have problems getting patients admitted to the hospital. This requires cooperation from the inpatient members of your team. My recommendation is to start with the front end, achieve some throughput improvement there, and then you are more likely to get the attention and support from hospital administration when you work on the back end."

Dr. Jensen described triage as "a process, not a place. It’s something we do. In a perfect world, triage consists of asking the patient’s name, eliciting a 2- or 3-sentence chief complaint, a set of vital signs, maybe a pain score, and that’s it. It is not a place to do medication reconciliation or to assess and teach about the need for vaccinations."

He advises clinicians to segment ED patients into vertical or horizontal categories. "The horizontal patients are the reason many of us went into emergency medicine in the first place: they’re hurt, sick, or there’s the potential for something seriously wrong," Dr. Jensen explained. "The vertical patients have simple, well-defined illnesses or injuries. We want patients with ankle sprains to get through the ED in 1-2 hours. At the same time, when an 80-year-old gentleman comes in with acute severe abdominal pain, if it takes us 6-8 hours to work up that patient, that’s a good thing. We are providing value-added diagnostic, therapeutic, and observational services. This is about understanding patient flow, segmenting your incoming patient streams, and mapping your care to the needs of those patients."

The goal is to "keep your vertical patients vertical and in motion," he continued. "For horizontal, badly sick, or badly hurt patients, it’s about real estate. You only want patients in beds who need beds, and you want them in beds only for as long as they need to be."

Dr. Jensen concluded by noting that there is no substitute for testing and prototyping a change in throughput process or performance. "You want to test your performance improvement efforts on a small scale, work out the bugs, build the collaboration of your teammates, get the data, and then go to hospital administration [for the support you may require]," he said.

Dr. Jensen said that he had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – In the opinion of Dr. Kirk B. Jensen, efforts to maximize patient throughput in the emergency medicine department are crucial.

A critical driver in patient satisfaction is how much time it takes for a patient to see a physician upon arrival. "I am not saying that the physician is the most important person in the equation in the emergency department, but from an operational standpoint the goal in your emergency department is to get the physician and the patient together as quickly as possible," Dr. Jensen said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

Patient satisfaction surveys are another driver. "We can quibble with the methodology of patient satisfaction surveys but they are clearly here [to stay] and they command our attention and measure our performance," said Dr. Jensen, chief medical officer at Raleigh, N.C.–based BestPractices, a division of EmCare, which provides ED management and staffing solutions. "Patient satisfaction declines as a function of time spent in the ED. The more time people spend with us, the less happy they are."

Another reason to pay attention to patient flow is the threat of malpractice. One review of wait times and claims per 25,000 patient visits at 36 emergency departments in California found that patients who waited more than 60 minutes to be seen were more than four times as likely to file a malpractice claim, compared with those who waited less than 30 minutes. "The longer it takes to see the physician, the more likely you are to get sued," said Dr. Jensen, who was not involved with the study. "There’s a direct, linear correlation. So when you want to get the attention of people on your ED team to rally around throughput and rally around improving productivity, you can always use data on malpractice and the risk of getting sued as a driver for changing behavior."

There is also a financial case for improving patient throughput in the ED. One ED in which Dr. Jensen assisted as a consultant had 40,000 patient visits per year and set out to reduce the average length of stay from 3 hours to 2 hours. "This generated 40,000 hours of new service delivery which meant a potential to see 20,000 more patients," he said. "If your average net revenue is $100 per patient and you can see 20,000 more patients, that creates $2 million in additional revenue for your physician practice and three to five times that for the hospital."

He advises clinicians to think about the path of an ED patient as having a beginning, a middle, and an end, and to look for ways to improve throughput at each juncture. In his experience, the points with the greatest leverage for throughput improvements are on the front end and at the back end. He described the front end as "the fly wheel that makes your ED hum. Focusing on those processes and that operation is critical to getting the kind of patient flow and throughput that you want. There are also opportunities on the back end, especially for those of us who have problems getting patients admitted to the hospital. This requires cooperation from the inpatient members of your team. My recommendation is to start with the front end, achieve some throughput improvement there, and then you are more likely to get the attention and support from hospital administration when you work on the back end."

Dr. Jensen described triage as "a process, not a place. It’s something we do. In a perfect world, triage consists of asking the patient’s name, eliciting a 2- or 3-sentence chief complaint, a set of vital signs, maybe a pain score, and that’s it. It is not a place to do medication reconciliation or to assess and teach about the need for vaccinations."

He advises clinicians to segment ED patients into vertical or horizontal categories. "The horizontal patients are the reason many of us went into emergency medicine in the first place: they’re hurt, sick, or there’s the potential for something seriously wrong," Dr. Jensen explained. "The vertical patients have simple, well-defined illnesses or injuries. We want patients with ankle sprains to get through the ED in 1-2 hours. At the same time, when an 80-year-old gentleman comes in with acute severe abdominal pain, if it takes us 6-8 hours to work up that patient, that’s a good thing. We are providing value-added diagnostic, therapeutic, and observational services. This is about understanding patient flow, segmenting your incoming patient streams, and mapping your care to the needs of those patients."

The goal is to "keep your vertical patients vertical and in motion," he continued. "For horizontal, badly sick, or badly hurt patients, it’s about real estate. You only want patients in beds who need beds, and you want them in beds only for as long as they need to be."

Dr. Jensen concluded by noting that there is no substitute for testing and prototyping a change in throughput process or performance. "You want to test your performance improvement efforts on a small scale, work out the bugs, build the collaboration of your teammates, get the data, and then go to hospital administration [for the support you may require]," he said.

Dr. Jensen said that he had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – In the opinion of Dr. Kirk B. Jensen, efforts to maximize patient throughput in the emergency medicine department are crucial.

A critical driver in patient satisfaction is how much time it takes for a patient to see a physician upon arrival. "I am not saying that the physician is the most important person in the equation in the emergency department, but from an operational standpoint the goal in your emergency department is to get the physician and the patient together as quickly as possible," Dr. Jensen said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

Patient satisfaction surveys are another driver. "We can quibble with the methodology of patient satisfaction surveys but they are clearly here [to stay] and they command our attention and measure our performance," said Dr. Jensen, chief medical officer at Raleigh, N.C.–based BestPractices, a division of EmCare, which provides ED management and staffing solutions. "Patient satisfaction declines as a function of time spent in the ED. The more time people spend with us, the less happy they are."

Another reason to pay attention to patient flow is the threat of malpractice. One review of wait times and claims per 25,000 patient visits at 36 emergency departments in California found that patients who waited more than 60 minutes to be seen were more than four times as likely to file a malpractice claim, compared with those who waited less than 30 minutes. "The longer it takes to see the physician, the more likely you are to get sued," said Dr. Jensen, who was not involved with the study. "There’s a direct, linear correlation. So when you want to get the attention of people on your ED team to rally around throughput and rally around improving productivity, you can always use data on malpractice and the risk of getting sued as a driver for changing behavior."

There is also a financial case for improving patient throughput in the ED. One ED in which Dr. Jensen assisted as a consultant had 40,000 patient visits per year and set out to reduce the average length of stay from 3 hours to 2 hours. "This generated 40,000 hours of new service delivery which meant a potential to see 20,000 more patients," he said. "If your average net revenue is $100 per patient and you can see 20,000 more patients, that creates $2 million in additional revenue for your physician practice and three to five times that for the hospital."

He advises clinicians to think about the path of an ED patient as having a beginning, a middle, and an end, and to look for ways to improve throughput at each juncture. In his experience, the points with the greatest leverage for throughput improvements are on the front end and at the back end. He described the front end as "the fly wheel that makes your ED hum. Focusing on those processes and that operation is critical to getting the kind of patient flow and throughput that you want. There are also opportunities on the back end, especially for those of us who have problems getting patients admitted to the hospital. This requires cooperation from the inpatient members of your team. My recommendation is to start with the front end, achieve some throughput improvement there, and then you are more likely to get the attention and support from hospital administration when you work on the back end."

Dr. Jensen described triage as "a process, not a place. It’s something we do. In a perfect world, triage consists of asking the patient’s name, eliciting a 2- or 3-sentence chief complaint, a set of vital signs, maybe a pain score, and that’s it. It is not a place to do medication reconciliation or to assess and teach about the need for vaccinations."

He advises clinicians to segment ED patients into vertical or horizontal categories. "The horizontal patients are the reason many of us went into emergency medicine in the first place: they’re hurt, sick, or there’s the potential for something seriously wrong," Dr. Jensen explained. "The vertical patients have simple, well-defined illnesses or injuries. We want patients with ankle sprains to get through the ED in 1-2 hours. At the same time, when an 80-year-old gentleman comes in with acute severe abdominal pain, if it takes us 6-8 hours to work up that patient, that’s a good thing. We are providing value-added diagnostic, therapeutic, and observational services. This is about understanding patient flow, segmenting your incoming patient streams, and mapping your care to the needs of those patients."

The goal is to "keep your vertical patients vertical and in motion," he continued. "For horizontal, badly sick, or badly hurt patients, it’s about real estate. You only want patients in beds who need beds, and you want them in beds only for as long as they need to be."

Dr. Jensen concluded by noting that there is no substitute for testing and prototyping a change in throughput process or performance. "You want to test your performance improvement efforts on a small scale, work out the bugs, build the collaboration of your teammates, get the data, and then go to hospital administration [for the support you may require]," he said.

Dr. Jensen said that he had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – If you or your emergency medicine group is audited, one strategy is to use the Marshfield Clinic Tool to help explain medical decision making – specifically how comorbidities, the differential diagnosis, and special studies affected the course of treatment.

This marks one of 10 audit defense strategies that Edward R. Gaines III, J.D., shared at a meeting on reimbursement and coding held by the American College of Emergency Physicians.

The other nine are as follows:

• Do not assume that the auditors have ED coding knowledge. Use the Emergency Medical Treatment and Labor Act (EMTALA) to help explain medical necessity in the context of emergency medicine. "A lot of medical directors and coders employed by the CMS Medicare administrative contractors and the Recovery Audit contractor auditors have no idea about EMTALA," said Mr. Gaines, who is the chief compliance officer of the Greensboro, N.C.–based Medical Management Professionals.

• Explain why you code with the presenting symptoms instead of with the final diagnosis. "Your auditor may be from a hospital background, and they’re all about the final diagnosis because that is how hospitals train their coders based on [American Hospital Association] inpatient standards," he said. See the government’s final ruling on this topic.

• Be thorough about the "nature of the presenting problem." "Explain how it impacts not only initial presentation but also comorbidities and the differential diagnosis," advised Mr. Gaines, who is also cofounder of the Emergency Department Practice Management Association.

• Insist on providers being part of the audit defense process. Use the audit "as an opportunity to educate the auditor and the client," he said.

• Make sure your documentation is true, accurate, and complete. This includes signatures on the E/M documentation, orders, and supervisory notes regarding nonphysician-practitioner and Physicians-at-Teaching-Hospitals documentation for residents. A free documentation template is available.

• Consult with counsel as appropriate, especially when large amounts of money are involved.

• Prepare a prompt and thorough response. "After the redetermination or reconsideration stages, you cannot submit any additional documentation evidence in the appeal, so you don’t want to find yourself limited," Mr. Gaines noted. "Submit complete and thorough documentation at the initial stages of the appeal."

• Don’t argue for the sake of argument. "If you missed the coding, just punt and maintain an expert, polite, and professional demeanor," he said. "That’s the best way to go to maintain credibility for the cases that you really want to argue about in the audit."

Mr. Gaines offered meeting attendees an 11th tip, a concept from Medicare case law known as the Treating Physician Rule. This rule states that deference should be given to the treatment decisions of the treating physician. "While deference is supposed to be given under the rule in Medicare cases, the deference does not rise to a presumption that the physician’s treatment was medically necessary and appropriate," Mr. Gaines stated. "The provider still has the obligation to show that services were medically necessary."

Mr. Gaines said that he had no relevant financial conflicts except as noted above.

[email protected]

SAN DIEGO – If you or your emergency medicine group is audited, one strategy is to use the Marshfield Clinic Tool to help explain medical decision making – specifically how comorbidities, the differential diagnosis, and special studies affected the course of treatment.

This marks one of 10 audit defense strategies that Edward R. Gaines III, J.D., shared at a meeting on reimbursement and coding held by the American College of Emergency Physicians.

The other nine are as follows:

• Do not assume that the auditors have ED coding knowledge. Use the Emergency Medical Treatment and Labor Act (EMTALA) to help explain medical necessity in the context of emergency medicine. "A lot of medical directors and coders employed by the CMS Medicare administrative contractors and the Recovery Audit contractor auditors have no idea about EMTALA," said Mr. Gaines, who is the chief compliance officer of the Greensboro, N.C.–based Medical Management Professionals.

• Explain why you code with the presenting symptoms instead of with the final diagnosis. "Your auditor may be from a hospital background, and they’re all about the final diagnosis because that is how hospitals train their coders based on [American Hospital Association] inpatient standards," he said. See the government’s final ruling on this topic.

• Be thorough about the "nature of the presenting problem." "Explain how it impacts not only initial presentation but also comorbidities and the differential diagnosis," advised Mr. Gaines, who is also cofounder of the Emergency Department Practice Management Association.

• Insist on providers being part of the audit defense process. Use the audit "as an opportunity to educate the auditor and the client," he said.

• Make sure your documentation is true, accurate, and complete. This includes signatures on the E/M documentation, orders, and supervisory notes regarding nonphysician-practitioner and Physicians-at-Teaching-Hospitals documentation for residents. A free documentation template is available.

• Consult with counsel as appropriate, especially when large amounts of money are involved.

• Prepare a prompt and thorough response. "After the redetermination or reconsideration stages, you cannot submit any additional documentation evidence in the appeal, so you don’t want to find yourself limited," Mr. Gaines noted. "Submit complete and thorough documentation at the initial stages of the appeal."

• Don’t argue for the sake of argument. "If you missed the coding, just punt and maintain an expert, polite, and professional demeanor," he said. "That’s the best way to go to maintain credibility for the cases that you really want to argue about in the audit."

Mr. Gaines offered meeting attendees an 11th tip, a concept from Medicare case law known as the Treating Physician Rule. This rule states that deference should be given to the treatment decisions of the treating physician. "While deference is supposed to be given under the rule in Medicare cases, the deference does not rise to a presumption that the physician’s treatment was medically necessary and appropriate," Mr. Gaines stated. "The provider still has the obligation to show that services were medically necessary."

Mr. Gaines said that he had no relevant financial conflicts except as noted above.

[email protected]

SAN DIEGO – If you or your emergency medicine group is audited, one strategy is to use the Marshfield Clinic Tool to help explain medical decision making – specifically how comorbidities, the differential diagnosis, and special studies affected the course of treatment.

This marks one of 10 audit defense strategies that Edward R. Gaines III, J.D., shared at a meeting on reimbursement and coding held by the American College of Emergency Physicians.

The other nine are as follows:

• Do not assume that the auditors have ED coding knowledge. Use the Emergency Medical Treatment and Labor Act (EMTALA) to help explain medical necessity in the context of emergency medicine. "A lot of medical directors and coders employed by the CMS Medicare administrative contractors and the Recovery Audit contractor auditors have no idea about EMTALA," said Mr. Gaines, who is the chief compliance officer of the Greensboro, N.C.–based Medical Management Professionals.

• Explain why you code with the presenting symptoms instead of with the final diagnosis. "Your auditor may be from a hospital background, and they’re all about the final diagnosis because that is how hospitals train their coders based on [American Hospital Association] inpatient standards," he said. See the government’s final ruling on this topic.

• Be thorough about the "nature of the presenting problem." "Explain how it impacts not only initial presentation but also comorbidities and the differential diagnosis," advised Mr. Gaines, who is also cofounder of the Emergency Department Practice Management Association.

• Insist on providers being part of the audit defense process. Use the audit "as an opportunity to educate the auditor and the client," he said.

• Make sure your documentation is true, accurate, and complete. This includes signatures on the E/M documentation, orders, and supervisory notes regarding nonphysician-practitioner and Physicians-at-Teaching-Hospitals documentation for residents. A free documentation template is available.

• Consult with counsel as appropriate, especially when large amounts of money are involved.

• Prepare a prompt and thorough response. "After the redetermination or reconsideration stages, you cannot submit any additional documentation evidence in the appeal, so you don’t want to find yourself limited," Mr. Gaines noted. "Submit complete and thorough documentation at the initial stages of the appeal."

• Don’t argue for the sake of argument. "If you missed the coding, just punt and maintain an expert, polite, and professional demeanor," he said. "That’s the best way to go to maintain credibility for the cases that you really want to argue about in the audit."

Mr. Gaines offered meeting attendees an 11th tip, a concept from Medicare case law known as the Treating Physician Rule. This rule states that deference should be given to the treatment decisions of the treating physician. "While deference is supposed to be given under the rule in Medicare cases, the deference does not rise to a presumption that the physician’s treatment was medically necessary and appropriate," Mr. Gaines stated. "The provider still has the obligation to show that services were medically necessary."

Mr. Gaines said that he had no relevant financial conflicts except as noted above.

[email protected]