In the emergency department (ED), denials and underpayments aren’t just billing issues – they’re operational threats that affect the entire healthcare ecosystem.
Current industry data shows ED denial rates average 15–20%, with coding and documentation errors accounting for a significant portion of the denials. This problem is not only hurting emergency medicine physician groups and hospitals – it’s also hurting patients. In fact, a survey from the Kaiser Family Foundation found that one in five insured adults who used emergency room services, said they received a bill from a denied claim.
A key driver behind these denials and underpayments lies in a critical but often overlooked challenge: the complexity of coding and charting compliance in the ED.
The documentation and coding dilemma
The unpredictability and fast pace of emergency medicine introduces risk into the revenue cycle, especially at the point of service documentation. If documentation is incomplete or coding isn’t aligned with the true complexity of care, claims get denied or reimbursed below value.
Coding accurately in the ED also means staying on top of evolving CPT guidelines, payer rules, and modifier requirements. Add the pressure of “clean claim” expectations from payers and the reality of documentation gaps across rotating providers, and it’s easy to see how errors and the resulting lost revenue add up quickly. In fact, even highly trained coders can struggle with inconsistent provider documentation styles and variability across hospital documentation systems.
These challenges can result in common and costly billing breakdowns, including:
- Inadequate support for high-level E/M codes (e.g., missing MDM details for 99285)
- Unbilled procedures (e.g., laceration repairs, intubations, central lines) due to unclear or omitted chart entries
- Missing or incomplete critical care documentation
- Inconsistent use of modifiers and diagnosis codes
- Coding delays caused by manual workflows and disjointed systems
Beyond revenue loss, these breakdowns contribute to a heavier documentation burden on emergency physicians, fueling administrative strain and burnout.
The hidden dilemma of ED administrative burdens
In a busy 24/7/365 environment, emergency room providers are under pressure to not only care for patients, but to ensure good documentation and coding that results in clean claims that meet revenue expectations.
These administrative burdens, combined with long shifts, heavy caseloads, and varying levels of patient acuity result in high levels of physician burnout. In fact, according to the American Medical Association, emergency medicine tops the burnout list, with 62% reporting levels of burnout, due in part to overwhelming bureaucratic demands.
The issue of burnout isn’t just a human resource issue – it’s also a financial issue. Estimates suggest the hidden costs of physician turnover, including recruitment costs, signing bonuses, onboarding and lost billings, is approximately two to three times a physician’s annual salary.
To address these overlapping challenges, ED groups must adopt smarter systems and workflows that can address financial and operational challenges, as well as physician-related administrative burdens.
Technology as the solution
Preventing denials and securing full reimbursement starts with getting coding and documentation right the first time. Partnering with a dedicated revenue cycle organization, who understands emergency medicine, can give ED groups access to scaled technology and specialized coding and compliance expertise that are difficult and costly to build in-house.
Using automation, intelligent logic, and seamless integration, Health Prime’s technology platform is built to drive ED improvements at scale by delivering key capabilities, including:
- Automated charge capture from hospital ED systems
- Captures every encounter and procedure directly from hospital systems
- Minimizes missed charges and manual entry errors
- Intelligent coding support
- Applies smart logic to guide accurate E/M, CPT, and procedure coding
- Flags incomplete or non-compliant documentation before submission
- Ensures modifier use and diagnosis codes meet payer-specific requirements
- Built-in compliance and payer rules
- Proactively addresses denial triggers with up-to-date payer logic
- Avoids rework, appeals, and delayed reimbursements
- Data-driven analytics
- Tracks denials by reason code, provider, location, and payer
- Monitors acuity mix and coding accuracy to identify gaps
- Empowers leadership to intervene before patterns become problems
The outcome: accurate reimbursement and less administrative burdens
Every underpaid claim is revenue left on the table. Every denied claim adds administrative burden. With Health Prime’s emergency medicine platform, groups get the clarity, control, and confidence they need to protect both revenue and provider well-being, while staying focused on patient care.
If you want more information about how our technology platform can streamline your coding and documentation, help reduce denials and underpayments, and improve both the physician and patient experience, please drop us an email or visit us at hpiinc.com/emergency-medicine.
