Half Increase Intensity Of Care Unexplained

Patient factors and increased clinical services explain <50% of billing increases

Emergency departments (EDs) bill more frequently at the highest levels of service than they did in prior years. This trend has generated questions as to whether the apparent rise in case severity is due to real changes in patient care needs or "upcoding" - the practice of coding cases at higher levels of complexity without any real change in the level of care performed. Though the term upcoding could connote fraudulent practices, like reporting more work than actually occurred, it may also be a result of legitimate and improved documentation aided by electronic health records.

Researchers recently analyzed Medicare claims data from 2006-2012 to delineate drivers of the increases in high-intensity billing (defined as CPT level 5 E&M 99285 or critical care 99291, 99292). They searched for common features of the high-intensity visits based on visit data, including patient factors (age, race, sex, Medicaid eligibility, comorbidities) and amount of services and procedures performed. Given its use of Medicare data, this study may not be generalizable outside of Medicare patients.
Patient factors and increased services accounted for a small to moderate amount of the increase in high-intensity visits. Variation attributable to these variables was 5.1% for inpatient (admissions), 47% for outpatient (discharges), and 15% of all visits.

Reclassifying observation visits as admissions did not change these results to a large degree. While up to half of the increase in billing intensity could be explained by the variables examined, more than half of the story remains unexplained. The remaining portion could come from upcoding or other factors not measured in this study. Examples of unmeasured factors that might dictate service intensity include clinical data (e.g. vital signs and lab results) and physician time spent. 

The drivers of the rise in complex ED visits and the contribution of upcoding remains an open question. It is likely an interplay of changes in clinical practice, the growing role of the ED in treating complex conditions, the increasing complexity of our patient population, as well as thorough documentation. Understanding drivers of visit intensity is necessary to assess if the coding system accurately stratifies the evaluation and management of patients by physicians. Policymakers and payers should root out clear cases of fraud but must recognize that higher intensity visits may represent increased, but unmeasured, real work.

PMID: 29382680

Burke LG, Wild RC, Orav EJ, Hsia RY. Are trends in billing for high-intensity emergency care explained by changes in services provided in the emergency department? An observational study among US Medicare beneficiaries. BMJ Open. 2018.


OBJECTIVE: There has been concern that an increase in billing for high-intensity emergency care is due to changes in coding practices facilitated by electronic health records. We sought to characterise the trends in billing for high-intensity emergency care among Medicare beneficiaries and to examine the degree to which trends in high-intensity billing are explained by changes in patient characteristics and services provided in the emergency department (ED).
DESIGN, SETTING AND PARTICIPANTS: Observational study using traditional Medicare claims to identify ED visits at non-federal acute care hospitals for elderly beneficiaries in 2006, 2009 and 2012.
OUTCOMES MEASURES: Billing intensity was defined by emergency physician evaluation and management (E&M) codes. We tested for overall trends in high-intensity billing (E&M codes 99285, 99291 and 99292) and in services provided over time using
linear regression models, adjusting for patient characteristics. Additionally, we tested for time trends in rates of admission to the hospital and to the intensive care unit (ICU). Next, we classified outpatient visits into 39 diagnosis categories and analysed the change in proportion of high-intensity visits versus the change in number of services. Finally, we quantified the extent to which trends in high-intensity billing are explained by changes in patient demographics and services provided in the ED using multivariable
RESULTS: High-intensity visits grew from 45.8% of 671 103 visits in 2006 to 57.8% of 629 010 visits in 2012 (2.0% absolute increase per year; 95% CI 1.97% to 2.03%) as did the mean number of services provided for admitted (1.28 to 1.41; +0.02 increase in
procedures per year; 95% CI 0.018 to 0.021) and discharged ED patients (7.1 to 8.6; +0.25 increase in services per year; 95% CI 0.245 to 0.255). There was a reduction in hospital admission rate from 40.1% to 35.9% (-0.68% per year; 95% CI -0.71% to
-0.65%; P<0.001), while the ICU rate of admission rose from 11.7% to 12.3% (+0.11% per year; 95% CI 0.09% to 0.12%; P<0.001). When we stratified by diagnosis category, there was a moderate correlation between change in visits billed as high intensity
and the change in mean number of services provided per visit (r=0.38; 95% CI 0.07 to 0.63). Trends in patient characteristics and services provided accounted moderately for the trend in practice intensity for outpatient visits (pseudo R2 of 0.47) but very little for inpatient visits (0.051) and visits overall (0.148).
CONCLUSIONS: Increases in services provided in the ED moderately account for the trends in billing for high-intensity emergency care for outpatient visits.

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems.

As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula.

This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.


Related Articles

Conference in Review: SIMS Conference 2018

Simulation has made an incredible impact on the world of medical education. Students have responded by creating the Student Initiative in Medical Simulation, an organization that is working to promote

Coming in Hot: Helicopter EMS Safety

Helicopter EMS is less dangerous than often portrayed, and safety is continuously being improved at all levels from the individual, aeromedical agencies, and national regulatory bodies.