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ED Coding and Reimbursement Alert

Sobering News:

Strategies for Alcohol and Drug Intoxication

Published on Tue Apr 01, 2003

Alcohol and drug intoxication have caused enough damage to your patients don't let these coded diagnoses block reimbursement for your ED.

What you don't know could hurt reimbursement rates. So watch out: Your payers may have a provision that allows them to deny claims with alcohol and drug codes. Health insurance policies sometimes deny medical reimbursement to patients under the influence of drugs or alcohol, states a Wall Street Journal article printed Feb. 26, 2003, "Why Emergency Rooms Rarely Test Trauma Patients for Alcohol, Drugs." These policies, based on state insurance laws, keep some physicians from running drug or alcohol tests for fear of losing reimbursement on procedures done for trauma patients, the article says. (See "Check Your State's UPPL Laws" in article 5 for a list of states that have these laws, and where you can find them.)

Do not be intimidated by these legalities. Report alcohol and drug intoxication diagnoses if your physician documented them. You will usually get paid, especially if the patient had other reasons for coming to the ED. The following additional pointers will help you stave off lost reimbursement from these diagnoses.

Trauma Comes Before Alcohol,Drugs

The first set of codes you should report for trauma victims should describe the main reason they presented to the ED, usually injuries, says Nettie McFarland, RHIT, CCS-P, coding manager at Healthcare Billing Systems Inc. in Daytona, Fla. List the alcohol and drug codes as secondary diagnoses. The first set of diagnosis codes, such as the injuries, will support the need for any procedures in addition to your E/M codes, she adds.You will almost always get paid for claims with two sets of diagnosis codes: injuries and then substances. In Michigan, health insurers pay about 50 percent of alcohol-related motor-vehicle accidents, the common culprit in trauma cases, and auto insurance the other 50 percent, says Sandra Pinckney, at Certified Emergency Medicine Specialists in Grand Rapids, Mich. "In these cases, we have never once been denied because of the alcohol."

Here are two typical examples of trauma victims who present to the ED with injuries and the presence of intoxicating substances. Following each scenario is the correct way to code it.

  • Example #1: EMS brings to the ED an unrestrained driver in a motor-vehicle accident (MVA). At the scene of the accident is a starred windshield, most likely from when the patient's head hit it. The patient complains of chest pain (likely from hitting the steering wheel) and has no or little recollection of how the accident progressed. There's a possibility that alcohol is involved. The physician performs a thorough exam neurologic, chest, cardio, respiratory, etc. The diagnoses for this case should be a head injury, such as 959.01 (Head injury, unspecified), chest contusion (922.1, Contusion of chest wall) and 305.00 (Alcohol abuse; unspecified), followed by V71.4 (Observation following other accident), Pinckney says.

  • Example #2: The patient arrives in the ED after an MVA, complaining of a head injury with facial lacerations, pain in the shoulder and the inability to move an arm. The patient smells of ethyl alcohol (ETOH). The physician orders x-rays of the face, skull, shoulder and arm, and blood work that includes a "tox screen." The  radiologist reports a dislocated shoulder, and lab work confirms ETOH intoxication with blood levels above legal limits. The procedures include a laceration repair of 3.5 cm for the face and manipulation of the dislocated shoulder. The patient is released into police custody.

    In this instance, you would report diagnoses 959.01 (Head injury, unspecified), 831.00 (Dislocation of shoulder; unspecified), 873.40 (Other open wound of head; face, without mention of complication, unspecified site) and 305.00. You should bill the procedures as 9928x (Emergency department services) for the E/M code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia), and 12013* (Simple repair of superficial wounds of face ...), McFarland explains.

    Ramp Up on Laws and Regulations

    Knowing your laws and legislation can help you with appeals. When you appeal these claims, defend your arguments with the appropriate legislation. "Insurance companies have a hard time supporting denials when you quote local legislation in your appeals," McFarland says. If this tactic fails, contact your state insurance commissioner when an insurance company denies claims for inappropriate reasons. And let the insurer know ahead of time of your plan. Usually if you let the insurance company know that you plan to contact the commissioner, the payer will reimburse your claims.

    Fight Harder for Nontrauma Diagnoses

    Sometimes a patient presents to the ED with only alcohol and/or drug abuse as the diagnosis. You're likely to see more denials with these claims.

    You may have to appeal claims to payers who deny them, but these appeals usually succeed, McFarland says. Here are two exemplary cases that may be denied and how to code them accurately. The second includes an example appeals statement that worked for McFarland.

  • Case #1: Afamily member brings to the ED a patient with an altered mental status. The confirmed diagnosis is drug abuse. The diagnoses in this case are 780.02 (Transient alteration of awareness) and drug abuse. You're more likely to get paid if you have that first diagnosis code, 780.02, although occasionally a commercial payer may deny 780.02 as well. The denial, however, "is very rare," Pinckney says.
  • Case #2: The patient is brought to the ED unconscious, and the physician documents that the patient is comatose. The patient smells of ETOH. The physician orders a complete workup with a differential diagnosis of diabetic coma and alcohol intoxication. The results show alcohol intoxication. In this case, you should report 780.09 (Alteration of consciousness; other) and 305.00 as the diagnoses. Use the ED services code 99285 to report the extensive E/M services the physician provided.
  • Appeals note: The carrier denied this claim as not medically necessary due to the diagnosis. Below is an excerpt of the appeal McFarland wrote based on both the guidelines from the Emergency Medical Treatment and Active Labor Act (EMTALA), a federal law governing assessment and transfer of patients seeking emergency care, and an article published by the Florida College of Emergency Physicians.

    Please reconsider your denial on this claim. The patient was unresponsive when he arrived at the Emergency Department. The medical record documents that a history was not available due to patient being in a coma. EMTALA guidelines require a full medical screening exam followed by appropriate stabilization, and absence of immediate medical attention could reasonably be expected to result in:

  • Placing the health of the individual in serious jeopardy
  • Serious impairment to any bodily functions
  • Serious dysfunction of any bodily organ or part.

    The article by FCEP goes on to state that "some intoxicated individuals may meet the definition of 'emergency medical condition'because the absence of medical treatment may place their health in serious jeopardy, result in serious impairment of bodily functions, or serious dysfunction of a bodily organ."

     

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