ED Coding and Reimbursement Alert

Receiving reimbursement for nonemergent cases can be difficult because although the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations state that the hospital cannot refuse a medical screening exam (see box on page 60), the carrier bases payment strictly on the level of medical decision-making or on the diagnosis submitted. A carrier might reduce or deny payment for nonemergency services performed in the ED or pay the hospital only -- and not the physician -- if it determines the presenting problem, as described by the submitted diagnosis, was not an emergency.
 
Medicare states that emergency codes must be paid regardless of whether the presenting problems are "real" emergencies. Codes 99281-99285 (emergency department visit for the evaluation and management of a patient) cover nonemergent care in the ED as long as it is:
 
1. an organized, hospital-based facility
2. open 24 hours
3. designed to provide services to patients who present for immediate medical attention for unscheduled episodic events.  
"When billing both emergent or nonemergent visits, do not confuse a clinical, medical opinion with a billing decision," says John Turner, MD, PhD, medical director of documentation and coding compliance for Team Health in Knoxville, Tenn. "The billing department cannot code based on emergent or nonemergent status, only according to what the medical record will support. A specific diagnosis or symptom cannot always dictate whether a patient's problem represented a true emergency condition. This is why CPT has not developed codes for emergent or nonemergent care." This is a problem because the service is not initiated by the provider or the insurer. Patients decide whether they're having an emergency, and that is why they come to the ED. EMTALA requires the hospital to see these patients, and it is only after the exam that the classification of emergent or nonemergent can be made.
 
For example, at 3 a.m. Sunday a worried mother comes to the ED with her baby, who has a high fever and is crying continuously. The emergency physician examines the infant and diagnoses otitis media (382.9), a minor inflammation of the middle ear. Although the diagnosis indicates that this was not an emergency, the mother was convinced that her child needed emergency care. Carriers, including Medicare, must pay the 99281-99285 ED E/M codes because the facility met its three nonemergent criteria.
Code According to Medical Record  
EMTALA mandates that every patient receive a medical screening, which is used to determine if the patient's condition qualifies as an emergency. If it does not, the physician does not have to provide care in the ED. But, there is little difference between the work required to determine the existence of an emergency medical condition and performing a regular E/M visit. To ensure reimbursement, it is better [...]