Analysis of Emergency Department-based Intensive Care Units on Coding and Revenue

Abstract

Introduction: Emergency department-based intensive care units (ED-ICU) address the increasing demand for critical care services and represent a transformative approach to the specialty's management of critically ill patients within emergency medicine. However, data on their financial impact and operational effects remain limited.

Methods: We conducted a retrospective, quasi-experimental study at an urban, academic ED with approximately 90,000 annual visits. In July 2019, a nine-bed ED-ICU model, referred to as "Next Pod," was implemented. We analyzed Current Procedural Terminology (CPT) coding data and professional revenue (charges billed and payments received) for 35 weeks before and after the intervention (November 2018-March 2020). The intervention involved repurposing a nine-bed ED area and adjusting physician and nursing staffing models. We compared critical and non-critical care CPT coding proportions and professional revenue using the Student t-test.

Results: During the study period, there were 38,283 ED visits pre-implementation and 36,424 visits post-implementation. Across the entire ED, critical care coding significantly increased following implementation (CPT 99291: 6.2 - 8.8% [total percentage increase of 41.94%]; 99292: 0.5 - 1.0% [total percentage increase of 100%]). Encounters where 99292 was billed multiple times increased by 128.1% (32 vs 73). Non-critical care coding (99282, 99283) decreased 23% (9.1% vs 7.0%, P< .001) / 29.6% (16.2 vs 11.4, P < .001), respectively. There was a non-statistically significant increase in 99284. Higher acuity codes (99285) increased by 10% (31.7% vs. 34.9%, P < .001). Average ED charges per visit increased by $40 (95% CI $37.2 - $45.5) post-implementation..

Conclusion: The implementation of an ED-ICU was associated with significant increases in critical care and high-acuity coding, as well as enhanced professional revenue. These findings suggest that ED-ICU models can improve both fiscal performance and operational efficiency. Further research is needed to explore the contributions of resource allocation, documentation improvements, and care practices to these outcomes.

Figure 1

Layout of Next Pod, including resuscitation and trauma rooms. Note that Next Pod area is the ED-ICU. Next Pod, North Pod Extension; WC, water closet; ED-ICU, emergency department-based intensive care units.

Figure 2

Layout of the study site emergency department. Total ED is 62,264 sq/ft. Next Pod is 2,653 sq/ft (occupying 4.26% of the total ED square footage). Note that Next Pod area is the ED-ICU. EMS, emergency medical services; Next Pod, North Pod Extension; ED-ICU, emergency department-based intensive care units.

Figure 3

Percentage of ED encounters with critical care time billed at study site before and after the implementation of Next Pod. Note that Next Pod area is the ED-ICU. CC, critical care; ED, emergency department; Next Pod, North Pod Extension; ED-ICU, emergency department-based intensive care units.

Figure 4

Percentage of emergency department encounters with critical care time billed at natural control site before and after the implementation of Next Pod. Note that Next Pod area is the ED-ICU. CC, critical care; Next Pod, North Pod Extension; ED-ICU, emergency department-based intensive care units.

Figure 5

Flow through the emergency department pre- and post-implementation of the Next Pod. Side A shows pre implementation, when trauma/resuscitation rooms were generally covered by Acute Pod 1. Side B shows post implementation where Next Pod generally covered the trauma/resuscitation rooms. Patients were triaged to the Next Pod primarily, or if deemed to need increased critical care resources, were transferred from other parts of the ED. If and when patients were stabilized or downgraded from the perspective of ED critical care resources, patients are then able to be discharged, cleared for EMH, or moved out to the main ED or hospital floors. Note that Next Pod area is the ED-ICU. EMH, emergency mental health; ICU, intensive care unit; Next Pod, North Pod Extension; ED-ICU, emergency department-based intensive care units.