Internal Medicine Coding Alert

Published on Sun Aug 31, 2003 PDF

If you're getting denials for claims made by your  internist and another physician for the same services performed on the same day, you're losing out on hard-earned pay. Coding experts advise that Medicare will pay both internists and emergency room physicians for same-day emergency department (ED) services (99281-99285)  - a little-known fact that you should use to your advantage. 
 
The Medicare Carriers Manual (MCM), section 15507, instructs physicians to use ED codes (99281-99285) when they provide care to a patient in the ED but do not admit the patient to the hospital.
 
MCM states, "If the ED physician, based on the advice of the patient's personal physician who came to the emergency department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of emergency department service. The patient's personal physician should also bill the level of emergency department code that describes the service he or she provided in the emergency department."
 
For example, a patient with heart disease (416.x) calls your internist and reports indigestion (536.8) and abdominal pain (789.0x). Your physician sends the patient to the emergency room. After examining the patient, the ED physician seeks advice from your internist on whether to admit the patient. Your physician evaluates the patient and decides not to admit. Instead, he or she advises the patient to visit the office the next day for tests and blood work.
 
In this case, you could report 99281 (Emergency department visit) to Medicare, for example, even if the ED coder does the same. In addition, you could link the same diagnosis codes to the services. You may report 99281 because your internist saw the patient in the ED and assumed the patient's care rather than simply rendering advice to the department's physician, says Jean Ryan-Niemackl, LPN, CPC, application specialist, QuadraMed Government Programs, Fargo, N.D.

Remember that you shouldn't use time as a factor when reporting emergency department codes - CPT has not established typical times for ED services, says David McKenzie, director of reimbursement, ACEP, Dallas. Also, your physician's documentation must meet all three components to justify the use of 99281: a problem-focused history, a problem-focused examination, and straightforward medical decision-making.
 
Medicare will not pay for your internist's telephone consultations (99371-99373) with the ED physician. Your physician must perform the evaluation in the emergency department. "If the patient's personal physician does not come to the hospital to see the patient, but only advises the emergency department physician by telephone, then the patient's personal physician may not bill." For example, the emergency department physician consults with your internist over the telephone about a patient's prescription medicine.
 
Although Medicare allows you to use an ED code - rather than an outpatient E/M code - when your internist sees a patient in the emergency department, private carriers have more stringent rules, Ryan-Niemackl says.
 
For example, when reporting codes for your physician's ED services to a private carrier, you should use the appropriate outpatient E/M codes (99201-99215), not the ED codes, when your internist treats a patient in the ED and doesn't admit the patient.
 
When the ED physician only asks for your internist's advice but doesn't request that your physician take over a patient's care, you should report consultation codes (99241-99245) instead of ED codes, McKenzie says. The MCM states that you should bill a consultation when your physician provides information to the ED physician for use in treating the patient.
 
Suppose one of your internist's patients with diabetes (250.xx) comes to the ED complaining of high blood-sugar levels (790.2) and disorientation (780.4). The ED physician requests a consultation from your internist to evaluate the patient. To qualify as a consultation, the internist's visit to the ED must meet certain criteria, including what are often referred to as the three R's: The ED physician requests the internist's advice, renders an opinion, and generates a written report,  Ryan-Niemackl says.
 
Your internist must also recommend treatment to the ED physician rather than provide it to the patient. For example, in the diabetic's case, the internist might recommend that the ED physician change insulin levels, and advise the patient, who has been drinking alcoholic beverages, to stop using alcohol due to its effect on blood-sugar levels.