Healthcare providers’ investment in Revenue Cycle Management is paying huge dividends…for healthcare providers…
From Fierce Healthcare:
the share of [patient] visits that were coded at higher intensities grew in emergency care, urgent care and physician office visits between 2018 and 2023. For example, the number of emergency department visits coded as 99284, or level four of five total, grew from 32.5% to 39.6% in the study window.
And this from Trilliant Health:
A 2021 Department of Health and Human Services Office of Inspector General report found that hospitals are increasingly billing inpatient stays at the highest severity level, raising concerns about systematic upcoding.1 From 2014 to 2019, these high-severity stays grew by nearly 20%, representing almost half of all Medicare inpatient hospital spending.
and this:
One study analyzing five states found that between 2011 and 2019, increased upcoding in hospital billing resulted in an estimated…$5.8B in additional payments from commercial payers.2
If you think this isn’t happening in workers’ comp, you aren’t thinking.
Of particular interest - injury upcoding increased 25% from 2018 to 2023
What does this mean for you?
Jeez, maybe facility cost increases aren’t due to “higher severity” injuries???
My wife has a lot of doctor visits and this drives me crazy. It's impossible to argue with the provider, they will never downcode a visit no matter how simple it was.
Hi Joe. Hospitals have various upcoding techniques that I used to find and defeat. Here's just one of many. They comb through lab reports and identify marginally out-of-range hemoglobin levels, e.g 13.9 gm/dL when normal range for males in their lab is , say 14-18. Then anemia gets retrospectively coded as a complicating diagnosis which raises the DRG group and payment level. And this occurs despite the fact that anemia is mentioned nowhere in the hospital progress notes or problem lists and no investigation or treatment is documented.