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Jump in High-Intensity Billing Driven by Case Mix, Upcoding

Analysis  |  By Jay Asser  
   December 15, 2022

New research finds that a significant rise in high-intensity billing since 2006 isn't solely due to coding practices.

High-intensity billing for treat-and-release emergency department (ED) visits has increased notably over the past 14 years, according to a study published in Health Affairs.

Researchers used the Nationwide Emergency Department Sample to examine treat-and-release ED visits and found that 19.2% of those visits exhibited high-intensity billing in 2019—a sharp rise from 4.8% in 2006.

However, the authors state that 47% of the growth in high-intensity billing was expected due to the changes in administrative measures for patient case mix and care services as data of later years showed higher proportions of older patients and those with more serious conditions.

While the researchers admit that the remainder of the growth may involve upcoding, the study highlights that coding practices alone aren't to blame. Providers have taken criticism from payers for their role in inflating high-intensity billing over recent years.

"Coding practices have become one element of an ongoing tug-of-war between payers and providers," the authors wrote.

The study also points to there being more clinical pathways and observation care for patients with more common but potentially serious issues, while more urgent care clinics are claiming low-acuity patients. With hospitals facing pressure to reduce spending, they have greater incentive to emphasize ED visits over low-value admissions.

The authors conclude that "future policy work must address controversies around high-intensity billing" given the context of shifting emergency care landscape, but payers must also recognize that patients are getting older and have more chronic conditions.

"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 study states. 

Jay Asser is the contributing editor for strategy at HealthLeaders. 


Nationwide Emergency Department Sample data was used to find that 19.2% of treat-and-release ED visits exhibited high intensity billing in 2019, compared to 4.8% in 2006.

Nearly half (47%) of the growth was expected because of changes in administrative measures for patient case mix and care services.

Upcoding has been an issue between providers and payers, but there are other factors leading to more high-intensity billing.

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