Emergency Department Downcoding Rate

What is Downcoding?

Downcoding occurs when an insurer decreases the E&M service level to a lower code, resulting in lower payment for the service delivered.  For example, submitting a charge for a level 5 emergency department visit (99285, the highest level) for “allergic rhinitis” is likely to be downcoded.

What can Downcoding mean for my practice?

Frequent downcoding means lost revenue for your practice and may signal that your practice could be a fruitful target for a RAC audit.

How can I prevent Downcoding for E&M services?

Document and bill for E&M services using the method outlined in the 1997 E&M Guidelines and submit diagnosis codes (ICD-9 or ICD-10) that support the level of service provided! Sounds simple, right?
Consider using an E&M coding cheat sheet so you can have the knowledge and confidence to bill at the highest level that is appropriate for the medical services you provide. Proper documentation and billing is the key to maximal clinical revenue.

What are E&M Services?

E&M services are easily recognizable medical services such as a visit to urgent care, hospital admission, or daily rounds on people admitted to a hospital. These services have multiple levels which correspond to different levels of medical complexity, such as a ‘emergency department visit – level 4’. Selecting the correct level of service is critical to being paid appropriately for the patient encounter. Medicare released guidelines on how to select the proper service level in 1995 and 1997. These E&M Documentation Guidelines serve as the rulebook for E&M coding for physicians in the USA.

Not all medical services are covered under the E&M Documentation Guidelines. Surgeries, lab tests, preventative medicine, counseling, and imaging studies have separate documentation rules.

What needs to be documented for E&M services?

The 1997 E&M Documentation Guidelines state that each patient encounter must include a medical history, examination, and medical decision making (MDM). Each documentation component requires certain types of information to be documented in the medical record.

Documentation Components from the 1997 Guidelines:

Medical History

  • Chief Complaint (CC)
  • History of Present Illness (HPI)
  • Past Family and Social History (PFSH)
  • Review of Systems (ROS)

Physical Exam

Medical Decision Making (MDM)

  • The number of diagnosis or management options
  • Amount and complexity of medical data reviewed
  • Risk of significant complications, morbidity, or mortality

References for the E&M Coding