ED Coding and Reimbursement Alert

Question: Should I bill for services that our ED physician provides to an inpatient? For example, one patient had a nosebleed, and the ED doctor went to the patient's room and performed limited cautery and placed limited nasal packing. The doctor also documented an expanded problem-focused history, along with an expanded problem-focused exam and moderate-level medical decision-making. We billed 99232-25 in addition to 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing], any method). Is this correct?
     
Ohio Subscriber

Answer: Yes, those codes are correct. You should report the subsequent hospital care code (99231-99233) supported by the chart documentation -- and don't forget to add any separately identifiable procedures your physician performed.

Also, keep in mind that a consultation requires documentation in the patient's medical record of a request (written or verbal) from a physician or other appropriate source. The consultant must then, in writing, communicate with a report back to the referring physician. Most emergency-room floor responses do not meet these criteria.

-- Reader Questions and You Be The Coder reviewed by Michael Granovsky, MD, CPC, FACEP, chief financial officer at Greater Washington Emergency Physicians in suburban Maryland.