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Billing and collecting for emergency services are crucial functions because they provide the revenue that supports emergency departments (EDs) and reimburse emergency physicians for the services they render to patients. Whether a practice is fully fee-for-service and self-supporting, is directly employed by the hospital, or requires a subsidy to meet its expenses, all of the legitimate revenue that is generated by the emergency physician should be collected. A sound, professional billing and collection process enhances contract security and provides support for appropriate ED coverage and competitive provider salaries.

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Billing and Collecting for Emergency Services: Basic Steps

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The billing process begins long before patient treatment with the establishment of contractual relationships between ED providers and insurance companies. The billing process continues with the ED visit, documentation of the visit on a medical record, and transfer of that record and insurance information from the hospital to the billing agent. Once the billing agent has received the record, it is coded for eventual payment of rendered services before being submitted to the appropriate payer for payment. Finally, the billing process ends when the billing agent receives appropriate payment.

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Many processes are required between each of these steps to ensure that appropriate payment is received. But what are these steps, and how can providers and the billing agents that serve them guarantee that they are collecting appropriate revenue for services? This chapter will address each of the billing steps in detail, and will review benchmarks against which a practice can be measured, as well as common pitfalls that often negatively impact the ED physician revenue stream. A glossary of terms is provided in Appendix 82-1.

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ED Record Generation—Types

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There are a variety of commercially available and locally developed ED treatment records, as well as services and software applications that generate a complete patient record. They include paper and electronic templates, EMRs, scribe services, and voice recognition software. Benefits and drawbacks are associated with each type of record.

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Paper records are generally quick to document and, if appropriately designed, incorporate checkboxes meant to enhance provider documentation, support code choice, and simplify billing processes. Relative to electronic and dictated records, paper records are not as easily interpreted by other providers (eg, the admitting doctor). This difficulty is due to legibility issues and the relatively limited amount of history of the present illness (HPI) and medical decision-making (MDM) that is often documented on a paper record.

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Commercial records generally have a cost per encounter, while locally designed records require that an employee of the practice take responsibility for keeping the record current with changes in

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  • “Quality reporting” measures for the physicians
  • “Core” measures for the hospitals
  • Medicare MAC interpretations regarding the elements of the 1995 Medicare Documentation Guidelines (DGs)

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For example, one Medicare administrative contractor (MAC) has repeatedly expressed concerns regarding the “ROS otherwise ...

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