Practice Management Alert

Question: One of my surgeons consulted on a Medicaid patient in the emergency room (ER) for an incarcerated umbilical hernia. The surgeon suggested using 99283 because the patient never left the ER, but the latest Medicare guidelines prevent this. What's the proper E/M code for this service?

Maine Subscriber

Answer: Each state Medicaid carrier sets their rules. So you first have to find out if your state's Medicaid is following Medicare's rules, which are ignoring consultation codes as of January 1, 2010.

Depending on the rules for your state Medicaid, you might use 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) if the Medicaid payer does not recognize consultation codes. Code 99283 is not limited to just the physician employed by the emergency room and may be billed by a physiciancalled in to evaluate an ER patient.

You could use 99243 (Office consultation for a new or established patient, which requires these 3 key components:...) if the Medicaid payer does recognize the consultation codes.

Because Medicare denies concurrent care, your surgeon can and should coordinate the diagnoses with the ER physician. The ER-employed doctor may charge an ER visit with signs and symptoms such as abdominal pain (789.0x) and the surgeon will use the more specific diagnostic codes. You should append 552.1 (Umbilical hernia with obstruction; parumbilical hernia specified as incarcerated, irreducible, strangulated, or causing obstruction) to your procedure code.

-- The answers to the Reader Questions and You Be the Billing Expert were provided or reviewed by Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network.