ED Financial Structure and Business

Question 1

In 2018, what percent of ED visits were done by independent APPs?

Answer 1

23%

Question 2

Roughly how many ED visits are there per year?

Answer 2

150 million

Question 3

Roughly how many EM physicians are there in the US?

Answer 3

40,000

Question 4

What are some proposed solutions to the oversupply of EM physicians?

Answer 4

• Increase residency length to 4 years to slow the rate of new docs
• Increase resident salaries to deter new programs starting for low-cost labor
• Outlaw for-profit residencies
• Decrease residents per program (voluntarily)
• Better delineate the scope of PAs to prevent midlevel creep

Question 5

By 2030, what is the projected supply and demand mismatch of EM physicians?

Answer 5

• Projected demand: 40,000
• Projected supply: 50,000

Question 6

What are some demand strategies to help ensure a vigorous EM workforce?

Answer 6

• Make an MD-led emergency certification program to reward EDs that have a high MD-to-APP ratio so that patients know where they can expect a high level of care (which would hopefully increase volume to EM doctors)
• Expand the role of EM physicians (obs units, POCUS, telemedicine, EMS, critical care, proceduralist services, correctional facilities, and psychiatric emergencies)
• Non-clinical roles: policy, research, advocacy, legal consulting

Question 7

What do you need to bill level 5?

Answer 7

• HPI: at least 4 elements
• ROS: at least 10 items
• PE: at least 8 organ systems
• 2/3 of FMH, Social, or PMH (can be one item as long as it’s specific)

Note: if you document a limitation to the HPI then you can get an exemption, such as for intoxication.

Question 8

Include the phrase “_____________” after your DDx in the MDM section.

Answer 8

among multiple other possible etiologies

This helps to clarify what you’re thinking and to leave the door open to other things.

Question 9

Why do you need to mention when you personally reviewed an image?

Answer 9

You get two MDM points for your personal review

Question 10

Why do you need to document that you reviewed old records?

Answer 10

You get two points for mentioning review of records.

Sand goes for mentioning obtaining corroborating info from family or EMS.

Question 11

What things are required for critical care documentation?

Answer 11

• A life threatening illness with organ dysfunction
• Urgent intervention by the provider
• Minimum 30 minutes involvement but not necessarily at the bedside

Question 12

If you’re documenting EKGs, you need at least _______________ elements.

Answer 12

Three

Question 13

What three things determine laceration reimbursement?

Answer 13

Location, length, and complexity

Question 14

Document whether you did __________ in an I&D.

Answer 14

whether you packed or probed

These make it a complex procedure.

Question 15

True or false: patients cannot refuse to have trainees participate in their care.

Answer 15

False

All trainee involvement must be disclosed as part of informed consent. Patients always have the right to refuse trainee involvement.

Question 16

Review HIV disclosure laws.

Answer 16

All new HIV cases are required to be disclosed to the department of public health. There are anonymous reporting systems to notify exposed people. Some states have laws that mandate reporting to exposed people and criminalize the withholding of HIV status to exposed people.

Question 17

The average ambulatory note in the United States is _______ times longer than notes in the rest of the world.

Answer 17

four

Question 18

Make your MDM focused on this: _______.

Answer 18

why you think the patient has X and why you think they don’t have Y

Question 19

What are E/M codes?

Answer 19

Evaluation and management codes

All ED visits are billed from 1 (least complex) to 5 (most complex). Nationally, 50% of ED visits are level 5 and the rest are mostly 3 or 4.

Question 20

What does it mean to get downcoded?

Answer 20

When a visit should have been a higher level visit (based on the chief complaint) but failed to meet the necessary documentation criteria and gets billed as a lower tier.

Question 21

What is needed to bill as a level 5 visit?

Answer 21

• Chief complaint
• HPI 4 elements (LOPQRSTAA)
• Two of the following: PMH, FMH, or SH
• ROS 10 items
• Physical exam 8 items

Question 22

Every level of ED visit needs a _____________.

Answer 22

chief complaint

Question 23

What is occurrence coverage?

Answer 23

It is malpractice coverage that covers you while you are at your job and after you leave.

Question 24

Claims coverage must also be paired with ______________.

Answer 24

tail coverage

Claims coverage works only for claims filed while you remain at your job.

Question 25

For looking at academic jobs, always ask what the likelihood of ________ is.

Answer 25

promotion (and how long this takes)

Ask what happened to the last 3 people who got the position.

Question 26

For all jobs, ask what happened to the last __________.

Answer 26

people who took the job (like did they stay, how long it took to get partner, etc)

Question 27

Review the requirements for the four levels of trauma centers.

Answer 27

I:
- Surgical residency and/or research program
- Full range of surgical specialists 24 hours a day

II:
- No surgical residency or research required
- Some surgical specialists 24 hours a day

III:
- No 24-hour surgeon requirement but some surgical capability
- ICU and emergency care capabilities

IV:
- No surgical requirements
- Must have a trauma-trained nurse and some form of 24-hour physician available but not ED doc

Question 28

What percent of ED collections are from L1-L5 charts, CC, and procedures?

Answer 28

Charts: 80%
Procedures: 10%
Critical care: 10%

Question 29

There are three columns of things that coders see. What are they?

Note, your chart is scored by the highest 2 of the 3.

Answer 29

Complexity and number of problems addressed
- Must include DDx and comorbid conditions

Amount and complexity of data reviewed
- Includes those you did review and those you considered and the rationale for not ordered
- The coding buzz words for reviewing is “independent interpretation”
- Includes specific notes and what you gleaned
- Consultants

Consideration of escalation of care:
- Should only be documented if you meaningfully considered it. If not, delete it! Good examples are if a patient declined admission or if you performed studies/observation that obviated the need of admission.
- Mention factors that affect patient risk such as homelessness, food insecurity, drug abuse

Question 30

Importantly, you only get credit for “independent interpretation” of __________.

Answer 30

one thing

Same thing for consults. You only get credit for documenting one conversation with a consultant.

Question 31

For the WEPPA template, delete the “considered admission” if you never considered admission.

Answer 31

… Just notes

Question 32

If you actually ordered a prescription medicine, then you do not need to note that you considered __________.

Answer 32

a prescription medicine

Question 33

Include in my usual template:

Answer 33

“Independent interpretation” of at least one radiograph or EKG

Document conversations with consultants.

Considered tests

Disposition considered

Historians listed

Social factors

Question 34

Review the ESI grading system (per the ABEM boards).

Answer 34

1: needs immediate life-saving care (e.g., intubation, Narcan, stroke, STEMI, trauma)

2: potential but so far unknown high-risk diagnosis; altered patients; concerning vital signs

3-5: all stable, vary depending on resources

3: stable but multiple diagnostic studies needed

4: stable, only one diagnostic study needed

5: stable, no diagnostic studies needed

Question 35

Review what you need to do prior to transfer to avoid EMTALA violation.

Answer 35

• Stabilize the patient to the best of your facility’s ability
• Certify that the benefits of transfer outweigh the risks
• Have a physician at the receiving hospital accept the patient
• Provide copies of the patient’s medical records to the receiving hospital
• Patient consents to transfer
• Organize transportation

Question 36

What are the two tiers of EMTALA violation fines?

Answer 36

Hospital with > 100 beds: $106,000
Hospital with < 100 beds: $53,000

Question 37

At what distance from a hospital does EMTALA apply?

Answer 37

250 yards