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Complexities of Emergency Room Billing and Coding

An emergency room or emergency department (ED) is one of the most critical facilities in any healthcare unit. An ED handles an unprecedented number of patients a day, all of them coming in without prior appointments and with varied illnesses, injuries, and other critical medical conditions.

Emergency room medical billing and coding processes are unique because of the lack of a routine that other departments have. Here are typical issues that arise with ED billing.

Complexities of emergency Room billing and coding

  • Instances of Discharges Not Fully Billed (DNFB)

EDs function 24X7, handling patients back to back and performing emergency procedures. This may leave the team with little time to verify documentation and ED charts. Incomplete documentation is the most common reason for claims denial.

DNFB is a common problem that occurs in practices that either have immense work volume or are understaffed. DNFB, over time, can lead to a dip in the cash reserves, causing stalling of the business altogether.

An expert medical billing and coding partner like Quintessence is what you need to handle DNFB issues. Our processes enhance workflow management, prioritizing efficiency and automation.

  • Terminology errors

There are a lot of complex terminologies used in an Emergency Room. For instance, Advanced Life Support (ALS) and Basic Life Support (BLS) have different codes, and interchanging their names or codes can lead to denials. Do remember that there could be thousands of such terminologies used in large hospitals, requiring billers and coders to work with precision and utmost focus.

  • Upcoding and Downcoding complexities

When it comes to ED billing, the charts are divided based on the complexity of the visit/procedure/care delivered. Each of these complex levels has its own codes, and mixing them up or missing a couple of them while documenting will lead to losses to the client or denials.

Check out some of these common complexity levels and their appropriate codes.




Routine checkups, returning back for a review, insect bites



Bleeding, adverse reactions to medications, overdose issues



Myocardial infarction, severe accident trauma, burns, suicides

Logically, the more complex the level of care provided, the more expensive it gets, and the claims will be higher.

For a medical billing and coding company, both upcoding and downcoding are problems. Upcoding is when the coder assigns a higher-level code to a particular care and bills it accordingly, but the insurance company denies it, stating that the care did not justify the higher code. This means you are going to go back and forth trying to settle the dispute, wasting your client’s precious time.

Downcoding is just the opposite. Let’s say your client had to provide the highest level of care for a complex condition in the emergency room, and you end up using a lower-level code for it. The insurance provider approves it, but your client ends up not getting their worth of time and effort. This will lead to significant revenue loss with time.

Now, this is why you will need a service provider who understands the complexities and unique challenges of ED medical billing and coding. Quintessence uses high-end AI tools that can quickly spot upcoding and downcoding and instantly show up an error. This makes it easy for coders to make the right changes, reducing the chances of manual errors. Our tools are also great to fill knowledge gaps, helping coders learn while they work.

  • Constant changes in billing terms

While the healthcare industry by itself is a place where change is constant, when it comes to the ED department, terms and conditions keep changing rapidly. It is necessary for medical billers to constantly keep track of billing requirements and changes. Insurance plans also keep changing, including or excluding certain ED procedures and treatments.

Just like how doctors have to keep updating their existing knowledge, people in the medical billing and coding industry need to be aware of the latest happenings too. If this does not happen, the denials rate will shoot through the roof.

  • Difficulty in patient/payer verification

In most cases, patients are rushed to the emergency room, and treatments have to start as early as possible. Unlike a planned surgery or treatment where the service provider has time to enquire about insurance details and verify the eligibilities beforehand, everything happens in a state of rush here.

It is important for an ED room to have dedicated staff that verifies patient and payer details and communicates them to the billing team to ease out billing and reimbursements.

The advantages of a well-prepped and efficient ED medical billing and coding team

Emergency Rooms are not exactly divisions of a hospital that are profit churning. According to experts, the average revenue margin of an ED is 7-8%. This means that unless the billing process is handled right, you may not be able to touch this average revenue margin too!

Another reason why revenues need to be discussed is that unless an ED department makes money, it may not be able to provide quality emergency healthcare for its patients.

Optimizing Revenue Cycle Management (RCM) in the ED section is the first thing healthcare providers need to do to maintain or improve their existing ED profits. Hiring third-party service providers to take over ED medical billing and coding will definitely help get a bird’s eye view of the current happenings and make relevant changes.

With expert RCM service providers like Quintessence, you can adapt to the industry’s best practices, make use of the tools and resources the service provider has, and work with some of the best billers and coders in the country.

Reimburssence, one of our AI tools, is designed to specifically track down bad touches, find out problem points in the current RCM process, and improve reimbursement rates. It does these by building a ‘collections work culture,’ predicting the results in advance, changing processes accordingly, monitoring claims until closure, and avoiding wasteful and repeat AR follow-ups.

Do you want to know more about Quintessence’s services and tools and understand how they can reinvent your ED medical billing and coding processes? Get in touch with us right away.