Emergency Department

Revenue Enhancement And

Compliance Reviews



A Special Portfolio of Services For

ER Compliance & Revenue Enhancement


Developed & Provided By

The Consultants At:


Abbey & Abbey, Consultants, Inc.


Ames, Iowa


A Member Of:


The HealthCare Consulting Group, L.C.

Contact Information:


Telephone: 1-515-232-6420 e-mail: Duane@aaciweb.com

FAX: 1-515-232-7496 Internet: http://www.aaciweb.com



ED - Revenue Enhancement & Compliance Review Services



The Emergency Department is one of the service areas for hospitals that creates significant problems and, in turn, significant opportunities. ER services represent a confluence of activities on the part of physicians, hospital facilities along with significant medical necessity and compliance concerns. There are many different ways to organize and structure the hospital and physician relations along with different methods for care paths, interfaces to other inpatient and outpatient services.


Financially the bottom line is that hospitals have Emergency Rooms that are marginally profitable or even operate at a loss. Through careful structuring, organization, proper coding, good documentation, up-to-date fee schedules and a properly organized Charge Masters hospitals can improve:


     The Quality Of Care Through Care Paths And Triage


     Improve Outcomes And Patient Satisfaction


     The Quality And Appropriateness Of Documentation


     Coding, Billing And Reimbursement


     Appropriateness Of Physician Fees And Hospital Charges


     Compliance Adherence To Coding and Billing Rules


     Compliance Adherence To EMTALA


     Reimbursement Under APCs and APGs



Using an Integrated Approach to the ED Challenge


The trick for addressing both revenue enhancement and compliance conformance in the ED setting is the need to bring expertise together from several different areas. The following areas must be considered individually and also as an integrated whole.


1.   ER Physician Coding - Surgical CPT - E/M CPT - Modifiers

2.   ER Physician Fee Structuring - RBRVS

3.   ER Physician Documentation Process & Compliance Standards

4.   ER Physician Charging Process

5.   ER Physician Claims Filing & Processing - HCFA-1500

6.   Facilities Coding - Surgical CPT - E/M CPT - Modifiers

7.   Charge Master Development - Facilities - Supplies - Drugs

8.   Charge Master Compliance Standards

9.   Charge Master Charge Structuring & Charge Algorithms

10. Triage - Medical Necessity - Care Paths

11. Interfaces - Observation - Inpatient - Urgent Care

12. Organizational Structuring & Physician-Hospital Interfaces

13. Structuring Services And Billing For EMTALA

14. ER Physicians And Physician Consultants


Add to this list other clinical concerns such as outcomes management and patient satisfaction along with general concerns of efficiency and effectiveness, and it is little wonder that the ED presents a complex opportunity for both physicians and hospitals.


In order for hospitals to meet the twin goals of:


        Being Properly Paid (Revenue Enhancement), and

        Being In Compliance (Compliance Adherence);


require a combination of skills, abilities and characteristics on the part of hospitals.

ER Revenue Enhancement & Compliance Review


The following is a generic sequence of tasks or steps that must be taken in order to both enhance revenues and ensure that compliance standards are being met. For any given hospital, this sequence may have to be tailored to meet special needs.


Tasks and Activities


The activities involved in addressing both revenue enhancement and compliance involve three main areas:


        Review of the ER sections of the Charge Master including the ER facilities section, ER professional services section and ancillary areas directly involved with ER services,

        A review of the entire service, documentation, coding, claims filing and reimbursement process,

        Review of the organizational structure involving the ER including both formal and informal arrangements

        A review of EMTALA compliance for both services and coding and billing,

        Training activities for coding, billing and ER staff personnel,

        Establishment of an organizational infrastructure to address ER coding, billing and compliance issues.



The activities and steps are outlined below.


Prior to On-Site Visit

1.     Review of the Charge Master sections for the ED and identification of any problem areas with coding, charges, modifiers, etc.

2.     Review of Encounter Forms and other manual mechanisms for charge input.

3.     Review of any documentation available concerning the organizational structure of ER services.




On-Site Visit


4.     Meeting with Revenue Enhancement Team (Business Office, Finance, HIM, IS) concerning overall process, objectives and schedule of activities.

5.     Review of how the Charge Master entries are being used, Encounter Form utilization, computer system capabilities and any associated problem areas.

6.     A review of documentation of selected ER cases for physician documentation and compliance with Medicare E/M documentation guidelines.

7.     Continuation of the selected ER cases by reviewing for proper code development for both physician and facilities coding including areas where there could be compliance concerns (e.g. proper application of CMSs Global Surgical Package with use of modifiers or billing for special observation services).

8.     Continuation of the selected ER cases by checking for proper reimbursement and any associated problems (e.g. CMSs Correct Coding Initiative denials).

9.     Continuation of the selected ER cases by reviewing the Charge Master and computer system interfaces relative to static and dynamic coding and proper generation of UB-92s and HCFA-1500s.

10. Study and assessment of the organizational structure for the ER, the ERs, relation to the hospital, contractual arrangements between the hospital and physicians, community physicians and ER services, etc. with the intent to ascertain possible compliance concerns.

11. Meeting with charge master personnel relative to recommended changes in the Charge Master.

12. Meeting with HIM coding personnel relative to coding problems and associated documentation concerns.

13. Meeting with ER staff relative to EMTALA compliance implementation,

14. Meeting with the Revenue Enhancement Team to discuss findings of the on-site assessment.

15. Meeting with the ER physicians as appropriate to discuss any recommendations relative to their activities and to discuss any possible compliance concerns.

16. Training session(s) for ER coding, billing and ER staff personnel relative to the documentation, billing, coding, and reimbursement process.


After Visit Activities


17. Preparation of final report concerning the assessment and recommendations relative to coding, Charge Master, documentation, APC/APG utilization and possible compliance concerns.

18. Telephone consultation (scheduled) to answer questions about the final report.





The deliverables fall into two categories:


1.     Discussions and guidance during the on-site visit,

2.     Education and training session(s),

3.     Final report detailing findings and making recommendations for changes.





The benefits involve:


1.     Increased revenues from ER activities, and

2.     Decreased compliance exposure.


Additionally, the final report will address any changes that need to be considered for optimization of revenues under APGs (Ambulatory Patient Groups) the new outpatient PPS (prospective payment system).




Costs for the services must be developed after a specific program of services has been established.



Distinguishing Characteristics of Abbey & Abbey, Consultants, Inc.



1.     Our activities are highly educationally oriented. Almost all studies involve special training for those participating in the process.

2.     One of our goals is to provide our clients with the infrastructure and resources to be independent for ongoing maintenance activities so that continuing consultation is generally not necessary.

3.     All of our services in the Charge Master and Revenue Enhancement areas include careful consideration of compliance issues.

4.     We will also review and address APC/APG issues both for the current implementations and future implementations.

5.     Consideration will also be given to any organizational structuring that can enhance current revenues and/or future payment systems.

6.     Access to a wide range of consultative and legal expertise in the health care field through our membership in the Health Care Consulting Group, L.C.


Contact Information


Duane C. Abbey, Ph.D., CFP

Abbey & Abbey, Consultants, Inc.

P.O. Box 2330

Ames, IA 50010-2330

TEL=515-232-6420 e-mail: Duane@aaciweb.com

FAX=515-232-7496 WWW: http://www.aaciweb.com