Upcoding isn't solely to blame for spike in 'high-intensity' ED billing, researchers say

A 14-year, pre-pandemic increase in the proportion of emergency department patients billed for “high-intensity” services can be explained—at least in part—by measurable changes in the types of patients seeking care and expansions in service offerings, according to a new study published in Health Affairs.

In response to concerns that fraudulent upcoding may be rampant across treat-and-release ED visits, healthcare policy researchers reviewed tens of millions of all-payer ED visit records.

The analysis reaffirmed prior reports that high-intensity billing had increased among these settings. Specifically, the researchers found that high-intensity billing initially represented 4.8% of the nation’s treat-and-release ED visits in 2006 but jumped to 19.2% of these encounters by 2019—a 10% or more increase per year across all patient age groups and payers.

However, they also noted that 47% of that growth “was expected” due to changes in administrative measures for patient case mix and care services and that by the end of the study period patients with potentially more serious conditions (e.g., chest pain) made up a larger share of treat-and-release ED visits than those with less serious conditions (e.g., sprains).

“Coding practices alone do not account for this trend,” researchers wrote in the journal’s December edition. “In addressing potentially inappropriate billing practices, payers must acknowledge the increasing complexity of care for a treat-and-release ED patient population composed of older, more comorbid, and clinically undifferentiated patients, to avoid hospitalization, ensure safe discharge and improve acute care outcomes.”

The researchers’ analysis used data from the Nationwide Emergency Department Sample, a collection of ED visit characteristics weighted to be nationally representative. The study sample increased from 5.5 million visits across 311 EDs in 2006 to 14.5 million visits across 670 EDs in 2019. Consistent with prior literature, treat-and-release visits with one of three CPT codes for high complexity or critical care (99285, 99291 and 99292) were considered to be instances of high-intensity billing.

The researchers wrote that their findings are consistent with prior research regarding the changing role of the ED in acute care.

The growth of urgent care clinics has claimed a large portion of low-acuity visits while primary care physicians have taken to referring complex patients to EDs for expedited diagnostic work-ups, they wrote. Further, pressure on hospitals to reduce spending has reduced low-value admissions and forced EDs to pick up the slack, they continued, all while nationwide demographics have shifted toward an older population with more chronic conditions.

“To meet these challenges, EDs have undergone substantial innovations, which might not be fully captured in claims data and therefore may contribute to the proportion of observed high-intensity billing noted in this study,” the researchers wrote. “Future policy work must address controversies around high-intensity billing in the context of these broader forces acting on the finances underlying emergency care.”