Cardiology Coding Alert

Although many cardiologists routinely bill encounters in the emergency department (ED) as consultations, in some cases this is inappropriate. National Medicare guidelines state that emergency department codes (99281-99285) should be used, unless these services qualify as admission (inpatient or observation) or critical care services.

In fact, there are at least seven different ways to bill an ED encounter, depending on the status of the patient:

1. Emergency room visit
2. Consultation
3. Admission
4. Admit to observation
5. Critical care
6. Established patient visit
7. New patient visit

These choices may make it difficult to code ED services provided by the cardiologist. To bill appropriately, coders depend on the cardiologists documentation of the encounter. Instead, what they often get is a short note that says, ED consult or Met patient in ED, without other documentation to support a consultation. To avoid claim denials, cardiologists need to provide expanded information of the encounter to their coders.

Consultations in the ED

Possibly the biggest area of confusion when cardiologists bill for ED services is consults. According to the Medicare Carriers Manual (MCM), If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are met.

The three criteria are stated in the MCM, section 15506:

1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by (the ED) physician.
2. A request for a consultation from (the ED physician) and the need for consultation must be documented in the patients medical record.
3. After the consultation, the consulting physician prepares a written report of findings that is provided to the (ED doctor).

In the hospital setting, a separate report is not required. The report can be an entry in the patients common medical records (i.e., progress notes, recommendations for treatment, etc.). Section 15506 states: In an emergency department or inpatient or outpatient setting in which the medical record is shared between the referring physician and consultant, the request for consult may be documented as part of a plan written in the requesting physicians progress note, an order in the medical record or a specific written request for the consultation. In these settings, the written report required for consult may consist of an appropriate entry in the common medical record.

If the criteria listed above are not met and the patient either is discharged from the emergency department or admitted to the hospital by another physician, the cardiologist contacted by the ED physician should bill an ED visit, not a consult. If the consultation criteria arent met, and the cardiologist admits the patient, an initial hospital care code should be billed.

Although many cardiologists believe [...]