Use Caution When Reporting Nursing Procedures on the ED Physician's Bill
Published on Wed Sep 01, 1999
Nurses often perform minor procedures in the Emergency Department under the supervision of the physician. Many coders wonder whether these services can be reported on the physicians bill since he or she ordered the procedure and supervised its performance.
The answer in most cases is no.
It is a controversial area, although it neednt be, says Gregory L. Schnitzer, RN, CPC, CPC-H, CCS-P, an audit specialist in the Office of Audit and Compliance at the University of Pennsylvania Health System.
Many of these procedures, which ED physicians are billing for actually are performed by nurses or other ancillary personnel, often have zero physician work relative value units (RVUs) assigned because it is understood that somebody other than the physician will be performing these tasks.
The total RVU values assigned to these procedures are often comprised of the office expense/overhead and malpractice expense component RVUs, with no actual work values assigned, he explains. The RVU value is designed to compensate the physician offices for their expense in performing the procedure.
Procedures commonly performed by nurses in the ED setting include:
therapeutic injections (90782-90799);
starting IV administration of medication (90780-90781) or, for thrombolysis infusion (92975-92977, coronary vessels; 37195, cranial vessels);
urine catheter insertions (53670*, catheterization of
urethra, simple);
removal of impacted ear wax, (69210); and
splint and strap applications (codes found in the Surgery/Musculoskeletal System/Application of Casts and Strapping 29000-29590).
For Medicare carriers and payers who follow the Medicare RBRVS, if the procedure is assigned zero physician work RVUs, then the emergency physician will actually see no reimbursement for this procedure even if it is reported.
It is sort of a moot point in that situation, Schnitzer notes. The site of service is always indicated on the bill. If the patient is seen in the hospital, the carrier knows not to include any practice overhead payment because the treatment is not delivered in an office setting.
However, some codes used in the ED do have physician work RVUs but are often performed by the nurse, but are occasionally done by the physician.
CPT codes are to be used for physician-provided services, adds Jackie Davis, president and CEO, of Term Billing, Inc., an emergency medicine billing company based in Arlington, TX. We do not report procedures when they are performed by nurses, unless there is documentation that the physician was there supervising the patient at the same time. And, really, the only reason the physician did not perform the procedure is that he or she was occupied performing some other task for the patient at the same time.
For example, the CPT definition for diagnostic or therapeutic infusions by IV specifically states that the [...]
