ED Coding and Reimbursement Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the
answer.   Question: Can I use non-ED E/M codes in the ED when the encounter is not for an emergency? For example, a patient comes to the ER for a wound check or for suture removal. We would like to code the visit as 99211 or 99212 rather than using 99281/99282. Is this allowed? Alabama Subscriber           Answer: It may be allowed, but it is not advisable. ED codes (99281-99285) are used to report all E/M services provided in the ED. The only thing these codes tell you is whether the services are provided in an emergency department setting, not whether the services are emergent. The ED codes make no distinction between emergent and non-emergent status.

E/M codes 99211/99212, on the other hand, are intended for established patients who are seen in either a physician's office or other ambulatory/outpatient setting and carry fewer RVUs. You cannot use office-based codes (99211-99215) in the ED. There are two problems. First, the POS (23 - Emergency) on the HCFA 1500 form will not match the CPT codes (office-based); and second, the ED codes specifically indicate that the patient's status, new or established, is incidental.

Some carriers may deny a visit stating that it was non-emergent - eg., cellulitus recheck or epistaxis packing removal and reassessment - and compromise by allowing codes outside of 99281-99285 due to the lower reimbursement. The carriers are deviating from the tenets of CPT in these cases. It used to be a common practice for community physicians to hold office hours on the weekends by using the ED as their office. In this circumstance, the hospital frequently did not charge the patients and sometimes did not even register them. EMTALA has effectively ended this practice. The situation you describe sounds like determining appropriate follow-up services to a procedure performed in the ED by an emergency physician. In this case, use an appropriately priced ED level of service on both the facility and physician components. The alternative is to refer the patient to another site of service. If the patient came to the ED instead of the doctor's office because it happened to be more convenient for the patient's personal physician, Medicare says that you should use a regular office/outpatient visit code ( CPT 99201 - 99215 ) for the services provided by that patient's personal physician. Special situations like this may occur where office codes may be the best way to represent the services for payment for the benefit of the patient, but most circumstances dictate the use of only ED codes. This question also involves the facility visit [...]