Physician/Coder Communication Critical for ED Services
Published on Sat Jul 01, 2000
Otolaryngologists typically get called to the emergency department (ED) for cases of severe epistaxis, nasal fractures and airway obstructions. Although such encounters routinely are billed as consultations by many otolaryngologists, this is inappropriate. National Medicare guidelines state that ED codes (99281-99285) should be used, unless services qualify as admission (inpatient or observation) or critical care.
In fact, there are at least seven different ways to bill an ED encounter, depending on the status of the patient:
1. ER visit
2. Consultation
3. Admission
4. Admit to observation
5. Critical care
6. Established patient visit
7. New patient visit
These choices make it difficult to correctly code ED services provided by the otolaryngologist. To bill appropriately, coders depend on the otolaryngologists documentation of the encounter. Instead, what they often get is a short note that says ED consult, or Met patient in ED without other documentation to support a consultation. To avoid claim denials, otolaryngologists need to provide a full explanation of procedures to their coders.
Consultations in the ED
Possibly the biggest area of confusion when otolaryngologists bill for ED services is consults. According to the Medicare Carriers Manual (MCM): If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are met.
The three criteria are stated in the MCM, section 15506:
1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a
specific problem is requested by [the ED]p physician.
2. A request for a consultation from [the ED physician]
and the need for consultation must be documented in the patients medical record.
3. After the consultation, the consulting physician
prepares a written report of findings that is provided to the [ED doctor].
In the hospital setting, a separate report is not required. The report can be an entry in the patients common medical records (i.e., progress notes, recommendations for treatment, etc.). Section 15506 states: In an emergency department or inpatient or outpatient setting in which the medical record is shared between the referring physician and consultant, the request for consult may be documented as part of a plan written in the requesting physicians progress note, an order in the medical record or a specific written request for the consultation. In these settings, the written report required for consult may consist of an appropriate entry in the common medical record.
If the consultation criteria listed above are not met and the patient either is discharged from the ED or admitted to the hospital by another physician, the otolaryngologist contacted by the ED physician should bill an ED visit, not a consult. If the consultation criteria arent met [...]
