ED Coding and Reimbursement Alert

Patient status and documentation will determine your code choice

When an ED physician is called to in-house codes or other emergencies, it’s essential to accurately document services and procedures. That documentation will guide your way to the correct codes.

For example: You may consider billing for an initial consult if all the requirements are met. In some circumstances the ED physician’s expertise is required beyond that of the hospital attending service, and the attending or other designee has requested their expertise.

Before coding for a consult, remember the three requirements (previously dubbed the three R’s): a request in writing in the medical record, a report that is written, and a return of care back to the initial provider.

Caution: Consultations are not appropriate as a matter of convenience when the attending service provider cannot see the patient due to other obligations, says Betty Ann Price, BSN, President and CEO of PRCS, Inc. in Palmetto, FL. Encourage the ED provider to also document the name of the person who requested the consultation. A written order for the consult is appropriate. It is important to know whether the patient status is Inpatient or Observation, as this drives whether you choose Inpatient Place of Service (POS) 21 (CPT^® 99251-99255) or Outpatient POS 22 (CPT^® 99241-99245) consultation codes.

Note: Medicare does not recognize consultation codes. Instead, you’ll more often report the appropriate inpatient or outpatient visit codes described below.

Alternatively, if the patient’s condition is critical and greater than 30 minutes of time is documented, that may support Critical Care (CPT^® 99291-99292), and when total recorded time critical care, exclusive of separately billable procedures, meets the established thresholds.. Otherwise, if the 30 minutes has not been met you may be able to charge subsequent hospital care (99231-99233).

Encourage providers to document performance of procedures such as CPR, tube placement, arterial, central venous, or intraosseous line insertions, paracentesis, thoracostomy, etc. In addition, peripheral IV insertion requiring physician skill may be captured with documented medical necessity (for example, multiple unsuccessful attempts by nursing staff).

When a patient is brought to the ED from a hospital bed during an emergency, the inpatient or outpatient observation status will typically not change from either inpatient POS 21 or outpatient POS 22. Your Evaluation/Management (E/M) coding options will depend upon whether the patient was admitted as a formal inpatient or an outpatient in Observation status, Price explains.

Partner Covering on the Same Day?

As long as the patient is an inpatient and services are provided during the inpatient stay, any E/M services provided by the emergency physician are subsequent to the initial inpatient service and should be billed that way, says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, Chief Executive Officer of Edelberg+Associates in Baton Rouge, LA.

In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit code descriptors include the phrase “per day” meaning care for the entire day.

If the physicians are each responsible for a different aspect of the patient’s care, payers will cover both visits if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty.

Don’t Forget: If the circumstances and documentation are such that justifying an E/M service is problematic, you should still report any procedures that were performed and properly documented, adds Edelberg.