General Surgery Coding Alert

Question: An emergency department (ED) physician asked our surgeon to see a patient with severe lower-abdominal pain. The ED doctor specifically requested that our surgeon take responsibility for treating the patient, so I don't think this can count as a consult. I-m not sure, however, if I can report an ED visit for our surgeon, who is not an ED physician. How should I report the visit?


New York Subscriber

Answer: A common misconception is that only ED physicians can report ED services (99281-99285, Emergency department visit for the E/M of a patient). In fact, any physician can report the ED codes if he provides a service in the ED. This does not mean, however, that an ED code is the only choice when a physician sees a patient in the ED.

According to the Medicare Carriers Manual section 15507, specialists should report an ED visit for services rendered in the ED, unless:

- the service provided meets the criteria for a consult

- the physician delivers critical care services (99291-99292) upon arriving at the ED, or

- the physician admits the patient to the hospital (99221-99223, Initial hospital care, for the E/M of a patient -; 99218-99220, Initial observation care, per day, for the E/M of a patient -; 99234-99236, Observation or inpatient hospital care, for the E/M of a patient including admission and discharge on the same date ...).

If your surgeon provides any of these three services, you should report the respective E/M service code instead of the ED visit.

In your case, the surgeon clearly accepted full care for the patient, so a consult is not an option. You don't mention any critical care services, so you wouldn't report 99291-99292, either.

If the surgeon subsequently admits the patient to the hospital (99221-99223) or observation (99218-99220), you should report that service. For a same-day admit and discharge, use 99234-99236.

As you describe your case, and because the ED physician transfers care to the surgeon, you should report an ED visit, such as 99282.

Private payer may not play ball: Some non-Medicare guidelines may indeed insist that only ED physicians can use ED service codes 99281-99285, which can force you to report outpatient E/M or consult services in defiance of CPT and CMS rules to keep within the individual payer's guidelines and receive payment for services rendered. If your payer stipulates such rules, be sure to get its recommendations in writing and follow them to the letter.