A photo of the exterior of the emergency department entrance to a hospital.

High-intensity billing for “treat and release” ED visits has increased since 2006

According to an observational study, high-intensity billing during “treat and release” emergency department (ED) visits has increased dramatically over the past two decades.

From 2006 to 2019, the share of emergency room treatment and discharge visits (those where patients were not admitted) that included high-intensity billing rose from 4.8% to 19.2%, researchers reported. researchers led by Alexander Janke, MD, MHS, of the VA Ann Arbor Healthcare System and the University of Michigan.

Additionally, the share of visits from patients with more comorbidities, older patients, and those with “nonspecific but potentially serious diagnoses” also increased, they said in Health Affairs.

“Mechanically, there’s a tug of war between physician groups and payers over reimbursement, and one of the places that tug of war is playing out is high-intensity billing,” VA National Clinician member Janke Scholars Program, Narrated MedPage today in a phone call.

His group found that only 47% of the increase in high-intensity billing was “expected” due to changes in administrative measures related to patient group and types of services available in claims data. “High-intensity billing” was defined as emergency department visits that included a CPT code reporting “high complexity” (99285) or “critical care” (99291 or 99292).

“Upcoding,” or submitting codes for more expensive procedures and diagnoses than those performed, was one possible reason for the upward trajectory of high-intensity billing, the researchers said. Janke’s group suggested that other reasons could be “correction of historical undercoding” when coding practices were more simplistic, or “wider changes” in the evolution of emergency care. For example, Janke recalled a senior colleague telling her that when she started practicing, any very elderly patient who presented to the emergency room after fainting would be admitted to the hospital.

But emergency medicine has evolved and is continually looking for ways to manage patients safely, while using fewer resources and minimizing hospitalizations, he explained.

Now, an older adult with multiple chronic comorbidities who presents with a nonspecific complaint and is assessed in the emergency department can receive careful risk stratification and plan to manage their condition safely at home, without requiring hospitalization, a- he declared.

“That’s sort of the most dramatic way the underlying complexity of emergency care has changed over the last two decades, and that’s what the data in the paper shows,” Janke said. .

He noted that the “planned” increase in high-intensity billing was based on information gleaned from basic claims data such as gender, age and diagnosis codes in a patient’s chart. What is not included are the social determinants of the patient’s health and the clinical complexity involved in their care, he explained.

“As we move towards alternative payment models [APM] for emergency care, we need to be sensitive to how the complexity of emergency care has changed, Janke said. For this reason, claims data alone is likely insufficient to understand this evolution of care, he argued.

“Any health policy works to better calibrate emergency care billing with the value to have to consider what is missing in these simple measures,” Janke noted in a follow-up email. “This includes things like the comprehensive management of older people with social or functional barriers to safe discharge, the growth of risk stratification tools to safely avoid costly hospital admissions, or the toolbox in expanding acute care providers to connect homeless patients to community resources. »

Janke said her group’s future research will include building datasets to better characterize the complexity of emergency care. This will be “key” to informing policy conversations about billing codes and developing APMs that “really improve the way we care for patients,” he said.

For the present study, the authors used the National Emergency Department Sample (NEDS) focusing on the period from 2006 to 2019, examining variables such as age, gender, disposition of visits to insurance status and the region of the emergency service site, among others. The analysis excluded patient visits that resulted in hospital admissions, transfers to other short-term facilities, or deaths. They cautioned that because observational care data is not reliably captured in the NEDS database, some visits in the treatment and discharge sample may have included patients receiving observational services. .

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    Shannon Firth has reported on health policy as MedPage Today’s Washington correspondent since 2014. She is also a member of the site’s Enterprise & Investigative Reporting team. Follow


Janke revealed support for a Resident Research Fellowship from the Emergency Medicine Foundation, the Department of Veterans Affairs (VA) Office of Academic Affiliations/National VA Clinician Scholars Program, and the University of Michigan.

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