Wiki Emergency Room Coding

[bethb]

Hi. I am finding some conflicting information regarding billing for physicians in the place of service emergency room.

Can any physician who sees a patient in the ER, regardless of specialty, bill using emergency room CPT codes 99281-99285?

For instance, an established patient of Dr. X goes to the ER. Dr. X happens to be at the hospital doing rounds at the time the patient presents to the ER. Dr. X is called down to the ER to see his patient. Can Dr. X bill from the 99281-99285 codes?

Another instance I question myself about is when a non-established patient presents to the ER and the ER physician calls Dr. Y (a specialist) and asks Dr. Y to see the patient in the ER. (the patient has Medicare in my example, so billing a consultation will not work) Dr. Y sees the patient in the ER. Can Dr. Y bill the visit from the 99281-99285 codes?

I have found different opinions for billing the situations. Can any physician, regardless of specialty, bill the ER codes if the physician sees the patient in the ER? Or are ER codes strictly for the ER physician?

Thanks!
Beth

 

[sivagurulingam]

Hi. I am finding some conflicting information regarding billing for physicians in the place of service emergency room.

Can any physician who sees a patient in the ER, regardless of specialty, bill using emergency room CPT codes 99281-99285?

For instance, an established patient of Dr. X goes to the ER. Dr. X happens to be at the hospital doing rounds at the time the patient presents to the ER. Dr. X is called down to the ER to see his patient. Can Dr. X bill from the 99281-99285 codes?

Another instance I question myself about is when a non-established patient presents to the ER and the ER physician calls Dr. Y (a specialist) and asks Dr. Y to see the patient in the ER. (the patient has Medicare in my example, so billing a consultation will not work) Dr. Y sees the patient in the ER. Can Dr. Y bill the visit from the 99281-99285 codes?

I have found different opinions for billing the situations. Can any physician, regardless of specialty, bill the ER codes if the physician sees the patient in the ER? Or are ER codes strictly for the ER physician?

Thanks!
Beth

Hi,

For the second scenario, I agree with 99281-85 ER code, because we are not able to bill consultation (medicare patient).
For the first scenario also like consult. When ER provider request the PCP to saw his/her patient in the ED we need to bill ER codes.

 

[sullivak]

Hi,

For the second scenario, I agree with 99281-85 ER code, because we are not able to bill consultation (medicare patient).
For the first scenario also like consult. When ER provider request the PCP to saw his/her patient in the ED we need to bill ER codes.

I realize that this is a very old thread, but I don't think this is correct. Yes, you can code 99281-5 in the ED for any physician regardless of specialty, but that is only if they are doing the ER workup. I know there's conflicting information out there, so please correct me if I'm wrong, but I've been coding for a consultant for several years and always code this way.

First scenario - an established patient of Dr. X goes to the ER. Dr. X happens to be at the hospital doing rounds at the time the patient presents to the ER. Dr. X is called down to the ER to see his patient. Can Dr. X bill from the 99281-99285 codes?

No, Dr X would code from the 99211-99215 (outpatient established) range with POS 23 (emergency room-hospital). Dr X could only bill 99281-5 range if he is the one who does the full ER workup (instead of the ED physician).

Second scenario - A non-established patient presents to the ER and the ER physician calls Dr. Y (a specialist) and asks Dr. Y to see the patient in the ER. (the patient has Medicare in my example, so billing a consultation will not work) Dr. Y sees the patient in the ER. Can Dr. Y bill the visit from the 99281-99285 codes?

If the patient were non-Medicare, Dr Y would code the 99241-5 consult codes with POS 23. However, since the patient has Medicare, Dr. Y would code the 99201-99215 codes with POS 23 depending on whether the patient is established or new to Dr. Y. For instance, if Dr. Y has seen this patient within the past 3 years in his office or hospital, he must use the follow-up codes 99211-5 for Medicare.

 

[thomas7331]

Medicare gave guidance on this at the time they stopped accepting consultation codes - you can find this in MLN Matters article MM6740: https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/mm6740.pdf

Emergency room services are addressed starting at the bottom of page 4, and it does say that both the ED physician and the consulting or personal physician should bill from the 99281-99285 code range - it is not limited to just the physician doing the ED workup.

 

[sullivak]

Medicare gave guidance on this at the time they stopped accepting consultation codes - you can find this in MLN Matters article MM6740: https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/mm6740.pdf

Emergency room services are addressed starting at the bottom of page 4, and it does say that both the ED physician and the consulting or personal physician should bill from the 99281-99285 code range - it is not limited to just the physician doing the ED workup.

Thank you so much for sharing this. I was totally mistaken. Fortunately, I've only rarely run into these scenarios over the years so (hopefully) have not messed up too many claims! :-S

I've copied and pasted the salient sections of the MLN Matters MM6740 article here-

Emergency department visits (Codes 99281 - 99288)-- physician billing for
emergency department services provided to patient by both the patient’s
personal physician and emergency department (ED) physician. If the ED
physician, based on the advice of the patient’s personal physician who came
to the emergency department to see the patient, sends the patient home, then
the ED physician should bill the appropriate level of emergency department
service. The patient’s personal physician should also bill the level of
emergency department code that describes the service he or she provided in
the emergency department. If the patient’s personal physician does not come
to the hospital to see the patient, but only advises the ED physician by
telephone, then the patient’s personal physician may not bill.

If the ED physician requests that another physician evaluate a given patient,
the other physician should bill an emergency department visit code. If the
patient is admitted to the hospital by the second physician performing the
evaluation, he or she should bill an initial hospital care code and not an
emergency department visit code.