Ob-Gyn Coding Alert

Emergency room visits can be complicated and may result in denied claims if the coding is not correct, especially when the patient is admitted to the hospital by the consulting ob/gyn.

Ob/gyn physicians are often called to the emergency room to see a patient, but is this a consultation or is it something else? One Ob-Gyn Coding Alert reader said they are repeatedly denied for these second consults because the ER physician has already used the ER services code (99281-85).

The key is to find out the nature of the visit first. A lot depends on the intent of the ER physician, observes Cynthia Thompson, CPC, a senior consultant for Gates Moore & Company in Atlanta. In most cases, according to Thompson, the ER physician is not asking for a consultation so they can care for the patient, but rather are asking the ob/gyn to take over. Rarely will the ER doctor call strictly for an opinion, which would qualify as a true consult. In most cases, the care rendered in the emergency room will be billed as an outpatient E/M service.

Outpatient E/M Service

But lets assume that the ER physician does not see the patient first, but the ob/gyn renders care to a new or established patient in the ER room. Can the ob/gyn bill using the ER department codes? Yes, but there may be better codes. This is because the ER codes have no time component and require that all three key components of an E/M service be documented. If this were an established patient, the physician would be better off reporting an outpatient E/M service.

Now what happens if the ob/gyn then admits the patient to the hospital? Then, says Thompson, the assessment would be included in the admissions coding. This is because of the CPT rule requiring that all E/M services provided on a given service date be billed as the most extensive E/M service. In the case of care given in the ER followed by hospital admission, the hospital admit code would be billed, and the level selected will account
for all E/M services performed that day.

The healthcare contract is another reason for not using the ER department code, states Barbara J. Cobuzzi, CPC, president of Cash Flow Solutions in New Jersey. This problem arises when the specialist uses the ER department code, but is denied because the hospital has a contract with a managed-care company in which the insurer pays the hospital or provider a fixed monthly fee based on the per-capita population in the hospitals service area. In that situation, Cobuzzi explains, claims for ER services may be automatically denied.

When to Use Consult Codes

Sometimes a consultation would be appropriate to code, however. One situation proposed by Cobuzzi is when the emergency room initially calls the wrong specialist. For example, a pregnant diabetic woman with alarming glucose levels may prompt a call for an obstetrician, who then recognizes that an endocrinologist is needed. In that situation, the obstetrician could use codes 99241-99245 (outpatient or office consultations).

Philip N. Eskew Jr., MD, medical director of Women and Childrens Services at St. Vincent Hospital in Indiana, also notes that documentation of the visit can be critical to securing payment, no matter which code type is selected. If a consult is billed, the documentation must clearly show that all the rules for a consult have been met. If an outpatient service and hospital admit occur on the same day, all services need to be clearly documented to allow a higher level of admit code to be selected and to rightfully get credit for all the work performed that day. If an ER department code is reported, make sure that all key components are appropriately documented for the level of code being reported.