Emergency services
Emergency service disputes will again be a focal point for fraud, waste and abuse investigations, with a particular focus on facility (hospital/freestanding emergency room (ER)) upcoding of evaluation and management (E/M) charges and challenges to payor policies on the handling of high-level E/M codes.
Emergency facilities coding differs significantly from emergency provider coding. Emergency provider billing refers to the professional services rendered based on the complexity and intensity of such services. Emergency facility billing, by contrast, is based on the volume and intensity of resources required for the care.
Recent reports show a trending shift in how ER facility E/M codes are reported, with a decrease in lower-level codes (99282 and 99283) and a corresponding increase in the two highest-level codes (99284 and 99285). This has caused investigations into the reasons for the shift, policy changes by some payors and ongoing payor/provider disputes as a result.
The American College of Emergency Physicians (ACEP), although an organization for physicians, has developed guidelines providing a general framework for ER facility billing of E/M codes. However, there is no national standard for ER facility billing, and less guidance (and therefore more ambiguity) exists for ER facility coding than for provider coding. Moreover, ER facilities are more often using software or algorithms to assign E/M codes, which may lend themselves to upcoding.
Emergency facility use of the ACEP guidelines and certain algorithms have faced legal challenges, including allegations that they facilitate upcoding and/or do not properly account for variations (such as size, volume, staffing and equipment) among emergency departments. Discovery (including expert discovery) will focus on the use of programs and algorithms to assign coding.
On the payor side, there has been an increase in litigation and arbitrations challenging payor policies intended to ensure accurate coding of ER facility E/M codes. This includes disputes over payors’ use of third-party vendors or software to flag certain high-level E/M claims for medical records and/or downcode high-level codes when certain criteria are met.
Such challenges require proactive steps. First, the payor should review and update its medical policies to educate providers and clarify the proper use of Level 4 and 5 facility services.
Second, the payor should set up routine requirements specifying whether and when records need to be submitted with claims to justify high-level coding.
Finally, it should consistently audit for trends in high-level E/M codes, particularly in cases where the patient is treated and released.
Of course, all the foregoing must be implemented consistent with any notice requirements in participating facility agreements.
Reimbursement for molecular panels
Molecular panels are laboratory tests that analyze multiple genes or biomarkers simultaneously to diagnose, predict or guide treatment for various diseases or conditions. Examples of molecular panels include genomic sequencing panels for cancer, pharmacogenomic panels for drug response and infectious disease panels for pathogen identification. Molecular panels can offer clinical benefits such as increased accuracy, efficiency and personalization of care, but may pose challenges for payors in terms of coverage, coding and payment policies.
One main challenge for payors is determining the medical necessity and appropriateness of molecular panels, especially when they include genes or biomarkers that are not well established, validated or clinically useful for the patient's condition. Payors also may face difficulties in applying consistent and transparent criteria for coverage and reimbursement of molecular panels, given the lack of standardization and regulation in the molecular testing industry. Furthermore, payors may encounter abusive or fraudulent billing practices by some laboratories or providers who perform or order unnecessary, duplicative or excessive molecular panels to inflate reimbursement. In many instances, providers are billing for molecular panels for routine urinary or wound care when there is no medical justification for these expensive tests that can cost thousands more than a routine urine collection and laboratory analysis. Related to this, there are concerns regarding laboratories courting professional providers to run tests in their offices in order to bypass payor policies that deny or limit reimbursement when performed by laboratories – particularly non-contracted ones.
To address these challenges, payors should consider implementing the following:
- Strong medical and coverage policies that clearly define the clinical indications, evidence requirements and limitations for molecular panels.
- Appropriate coding and payment methodologies that reflect the value and complexity of molecular panels, and discourage overutilization and unbundling of tests.
- Enhanced data analytics and audit capabilities to find outliers, trends and patterns in molecular panel billing and utilization, taking corrective actions when needed.
Remote neuromonitoring
Remote neuromonitoring (RNM) is a type of telehealth service that involves the continuous or periodic monitoring of a patient's neurological activity by a qualified professional located remotely from the patient. RNM can be used for various purposes, such as detecting seizures, assessing brain function, guiding neurosurgical procedures or managing chronic pain. RNM can potentially improve patient outcomes, reduce complications and lower costs by providing real-time feedback, diagnosis and intervention.
However, RNM is also an area of concern for payors as it may be subject to inappropriate or excessive use, billing or reimbursement. Some of the issues that payors may encounter with RNM include:
- Lack of clear medical necessity or clinical benefit in certain situations, such as routine or low-risk procedures, asymptomatic or stable patients, or prolonged or indefinite monitoring periods.
- Lack of proper supervision, credentialing or documentation of the RNM service by the remote professional, or lack of coordination and communication with the treating physician or facility.
- Improper coding or billing of RNM services, such as using incorrect or outdated codes, unbundling or upcoding of components, or double billing for the same service by multiple providers or facilities.
- Inflated or unreasonable charges or reimbursement rates for RNM services, especially when compared to similar or alternative services.
To prevent or mitigate these issues, payors should develop and enforce robust medical and coverage policies that specify the criteria, standards and expectations for RNM services. Payors should also verify the accuracy and validity of RNM claims, and ensure that they are consistent with the plan terms, coding guidelines and payment rules. Moreover, payors should monitor and audit RNM claims and providers for any signs of fraud, waste or abuse, and take appropriate actions to recover overpayments or prevent future violations.