ED Coding and Reimbursement Alert

Emergency department (ED) physicians occupy a unique position in the healthcare field one that causes big challenges for coders. Often, doctors in an emergency setting collaborate with their medical colleagues to provide the best care for patients. They may work with cardiologists when an elderly patient presents with severe heart dysrhythmias, with members of a specialized trauma team following a grievous automobile accident, and with radiologists to determine the cause of a young patient's headache. These scenarios raise a dilemma for coders.
Who Codes, Bills and, Ultimately, Gets Paid for These Shared Services?
"Concurrency-of-care issues within emergency medicine have been debated over the course of many years," says Kenneth DeHart, MD, FACEP, president of Carolina Health Specialists in Myrtle Beach, S.C., and past member of the CPT Editorial Panel. "CPT makes it very clear that physicians may submit any CPT code for which they provide service. However, many payers are equally clear that they won't reimburse two physicians for the same service provided to the same patient on the same day."
 
When deciding which physician to pay, he adds, payers use rules that may be capricious and arbitrary. "In some cases, insurers try to determine who did the most work and award the benefit in that manner. At other times they simply pay whichever physician's bill is received in their offices first."
 
In addition to impacting the bottom line, these issues also strain collegial relations within the facility, he notes. Each physician who cares for the patient feels entitled to reimbursement, and resentments flare when payments end up in another practice's coffers.
Strategies to Maximize Payment
To take the guesswork and politics out of coding and reimbursement, DeHart recommends three strategies:

  Document thoroughly and submit supportive paperwork. When claims are submitted with documentation that clearly substantiates the services, insurers are more likely to respond with full payment. "A lot of coders balk at the idea of having to send paperwork in to insurance companies," says Carol Dodd, RHIT, senior coding consultant in the department of coding and information services with Medquist in Gibbsboro, N.J. "But we must remember that the coding process was not developed to exclude physicians from getting what they earn. When coders take a little extra time to dot their I's and cross their T's, they can show the payers the documentation that demonstrates that a specific level of service was truly provided. Then the practice will get paid what it deserves." 

  Develop specific policies with other departments that address concurrent care issues before they arise. Communication is key, DeHart says. "Often, this has to be decided within the local political environment. The hospital must establish policies that treat contributing physicians fairly." Then coding experts can work cooperatively to [...]