The emergency department has become "a central staging area" for the acutely ill, according to Dr. Stephen Pitts, associate professor in the emergency medicine department at Emory University School of Medicine, Atlanta. The perspective piece notes that Level 5—the most serious—ED visits have increased from 27% of all Medicare discharges to 48% between 2001 and 2010. The most common symptoms leading to these discharges—abdominal pain, chest pain and shortness of breath—can now be diagnosed and risk-stratified in the emergency department using high-tech imaging, leading to fewer calls for surgical consultations and fewer hospitalizations.
Also contributing to higher billing is an "increasingly interventionist ED practice style" that has led to the initiation of more laboratory tests and initiation of intravenous fluids, Pitts wrote.
"Whether this trend has truly improved patient safety and quality of care is unknown, but it has certainly increased the complexity of the medical decision-making component of documentation, which translates into higher physician billing," Pitts wrote.
Defensive medicine, too, may also play a role, he said.
"Failure to diagnose patients' conditions carries heavy penalties for ED physicians and hospitals, whereas 'overuse' of technology is ill-defined, and penalties for it are less direct," Pitts wrote.
Electronic health-record systems help emergency-room personnel document all care provided by "presenting clickable check-boxes that easily satisfy coding-complexity criteria," he said. This ensures that "no billable action goes unnoticed," he wrote—but that doesn't mean fraud is occurring, as a federal auditor's report from this fall on evaluation and management visits suggested.
An HHS inspector general's office analysis of Medicare cost increases for E/M visits concluded that physicians' increased billing for more-expensive services was driving higher costs. Subsequently, Attorney General Eric Holder and HHS Secretary Kathleen Sebelius sent a letter to five hospital trade associations expressing their concerns that "some hospitals may be using electronic health records to facilitate 'upcoding' of the intensity of care or severity of patients' conditions as a means to profit with no commensurate improvement in the quality of care."
Pitts, in his report, acknowledged that EHRs are "one reason behind increased ED billing, and fraud may be facilitated by these new systems." However, he said, "This simple explanation does not capture the broader story of what happened in U.S. EDs during the decade the OIG examined.”
The American College of Emergency Physicians, in a news release, accused news organizations of having "embellished" the assertion that widespread upcoding was occurring.
ACEP President Dr. Andy Sama argued that emergency department care has become more complex in part because primary-care physicians now often send patients to the ED for "more prompt and definitive work-ups."
"Care that used to be provided on in-patient floors is now being done in emergency departments," Sama said in the release. "But this puts the burden of accurate and efficient diagnosing on emergency physicians, which leads to higher complexity and higher-billed visits."