Emergency Departments operate in high-pressure environments that present unique challenges from a billing and coding perspective. The combination of unpredictable patient volumes, high-acuity cases, and complex presentations requires emergency physicians to assess, stabilize, and treat patients based on symptoms rather than definitive diagnoses – often without regard to insurance coverage. This dynamic creates friction with payers as reimbursement frequently depends on how closely clinical care aligns with payer expectations.
At the center of this process is clinical documentation, which must simultaneously meet the needs of multiple stakeholders. Clinical documentation requires detailed information that balances medical, legal, and billing/coding perspectives, which may sometimes be at odds with each other. Additionally, documentation must be completed promptly to serve as an effective communication tool for both inpatient and outpatient care. However, the fast-paced nature of emergency medicine often limits the time available for meticulous note-writing, posing an ongoing challenge for physicians.
Taken together, we have a perfect storm for denials, down-codes, and underpayments. According to the American Hospital Association’s 2024 Costs of Caring report, Medicare paid only 82 cents for every dollar hospitals spent caring for patients in 2022, resulting in a shortfall of almost $100 billion. This economic shortfall hit Emergency Departments particularly hard, the report noted, due to the increasing acuity of our aging patient population and the high number of Medicare and Medicaid patients that are seen in EDs. For perspective, there are an estimated 10,000 baby boomers turning 65 years old every day through 2030.
In 2025, Emergency physicians can expect more financial blows, with hundreds of CPT code adjustments and a 2.83% decrease in the Medicare Physician Fee Schedule (PFS) conversion factor – the fiscal building block of all physician reimbursement in the fee-for-service world of American healthcare. The 2025 CPT code set represents 420 updates, including 270 new codes, 112 deletions, and 38 revisions. The new modifications reflect recent medical technology advancements, new procedures, and the streamlining of older codes to improve clarity. The 2.83% drop in the Medicare PFS conversion factor this year represents the fifth consecutive year of reductions and nearly a 12% reduction of the same time period. This unfortunate PFS CF decrease results from the expiration of a temporary Congressional update that expired at the end of 2024 and will remain unless Congress implements a new Legislative fix.
At the same time, commercial payers continue to employ numerous tactics to deny claims and reduce payments. They frequently change billing rules and guidelines, often without notice, creating administrative burdens and financial uncertainty for emergency physicians. Payers also request excessive amounts of clinical documentation or require prepayment audits before processing claims, delaying reimbursements and complicating cash flow. Compounding these challenges, emergency physicians will continue to feel the effects of patient protection laws such as the No Surprises Act and the Emergency Medical Treatment & Labor Act (EMTALA), which are being exploited by payers to deny claims and shift the payment burden to physicians after care has already been delivered.
Knowing that emergency departments must treat all patients regardless of socioeconomic status, payers take advantage of this mandate by down-coding services and paying based on the final diagnosis rather than presenting symptoms, which is a clear violation of the Prudent Layperson Standard. These exploitative practices undermine emergency care and require vigilant advocacy and comprehensive solutions.
What can providers do to maximize reimbursement and thrive in this challenging environment?
The following proactive strategies can help providers improve Emergency medicine billing and coding and position their practices for long-term success.
Emergency Medicine Billing: A Team Sport for Financial Success
In today’s challenging financial landscape, emergency physicians and their billing teams can no longer operate in silos. Emergency medicine billing and coding must be viewed as a collaborative partnership between clinicians and billing experts. Achieving accurate and timely reimbursement demands synchronized efforts and open communication.
Getting Started: Master Billing Guidelines and Build Partnerships
The foundation of successful Emergency Department (ED) billing lies in staying current with the latest billing guidelines and code updates. The billing and coding team must ensure that claims are procedurally clean and align with payer requirements. However, this is only part of the equation. Effective communication between coding teams and physicians is equally essential.
Coders must work closely with physicians to communicate guideline expectations and provide feedback on clinical documentation. Physicians play a crucial role in delivering detailed and accurate chart notes that support appropriate billing and coding.
Key Documentation Elements for ED E/M Levels
When preparing claims, coders require three critical medical decision-making components to assign the correct ED Evaluation and Management (E/M) level code to a chart:
Complexity of Problems Addressed (COPA): Descriptions of the patient’s condition and the complexity of their management.
Data: Tests ordered, consults with specialists, and diagnostic information.
Treatment Risk: Potential risks associated with treatments, medications, or procedures.
The documentation details in these categories communicate Low, Moderate, or High severity. The highest of two out of the three categories determines the appropriate Current Procedural Terminology (CPT) code for appropriate ED E/M level coding.
The Consequences of Incomplete Documentation
When key documentation elements are lacking or missing from ED clinical charts, medical groups face potential revenue loss in several ways:
Under-Billing: Coders may assign lower acuity levels, resulting in lost revenue.
Missed Eligible Services: Opportunities to bill for eligible services may be overlooked.
Claim Denials: Payers may deny claims if documentation does not support the assigned codes.
Payment Delays: Payers may request audits or additional documentation, leading to significant payment delays.
Given the increased scrutiny from payers, clean claims and accurate documentation are critical to maintaining appropriate revenue streams.
Action Steps for Better Billing and Documentation Alignment
To improve billing and documentation practices, consider the following actionable steps:
Ongoing Education: Provide regular training for both physicians and coding teams on billing guidelines, new codes, and documentation best practices.
Documentation Audits: Conduct routine reviews of clinical documentation to identify and correct gaps before claims are submitted.
Feedback Loop: Establish a system where coders can provide real-time feedback to physicians on documentation improvements.
Standardized Templates: Develop documentation templates and firm emergency room billing guidelines that prompt physicians to capture the necessary elements for accurate coding.
Performance Metrics: Monitor key performance indicators (KPIs) such as clean claim rates, denial rates, and days in accounts receivable to assess and optimize billing operations.
Emergency medicine billing and coding is truly a team sport. By fostering a collaborative relationship between physicians and billing experts, practices can navigate the complexities of modern healthcare billing, improve denial management, and secure appropriate reimbursement. A shared commitment to documentation excellence and clean claims will position practices for success in an increasingly challenging financial environment.
How Ventra Can Help
As these strategies and action steps suggest, basic billing and coding are table stakes now. To maximize reimbursement, practices need not only expert billing but also provider education, powerful data & analytics, payer contracting guidance, and more.
Our vSight™ data & analytics platform was built and is continually optimized by data professionals who understand the nuances of Emergency medicine. We also created a Performance Surveillance Team to focus solely on daily monitoring of more than 200 audit controls, watching for issues that may impact performance and working cross-departmentally to address them proactively.
Importantly, our Client Success team is on hand to proactively help you understand your data, working closely with our Provider Education team to help improve coding accuracy, improve physician documentation, and reduce audit challenges. With direct billing and coding experience, these teams are highly analytical partners who are focused on streamlining the revenue cycle and achieving appropriate reimbursement.
2025 promises to be another year of regulatory and reimbursement challenges by the healthcare insurers. However, by implementing proactive, collaborative, and data-driven strategies, ED physicians can help ensure they get paid appropriately for the Emergency care they deliver. Partnering with Ventra for your RCM needs will make meeting these challenges achievable, understandable, and tolerable.
