Primary Care Coding Alert

Confusion over when to bill for a consultation and when to bill emergency department (ED) services can stop now. The key factor is the intent behind the ED physician's request to the FP.

"Is the ED physician asking for an opinion?" asks Jean Ryan-Niemackl, LPN, CPC, compliance analyst for MeritCare Health Systems, a multispecialty system in Fargo, N.D. Or is the ED physician asking the other physician to take over care of the patient? When to Use an ED Code If the ED physician is asking the FPto assume care of the patient and the patient is not admitted to the hospital, use the ED codes.

For example, an elderly patient with a history of heart disease calls her FPand complains of indigestion and abdominal pain. The FPdirects her to the ED. The ED physician examines the patient, is not sure whether she should be admitted, and asks the FPto come to the ED to evaluate her. After arriving, the FPtakes a history, examines the patient and decides not to admit, instead advising the patient to come to the office the next day for tests and blood work.

The ED physician codes the appropriate ED code based on his or her level of involvement in the case, and the FP does the same. Both diagnosis codes can be the same.The ED codes are properly used here because the FPsaw the patient in the ED and assumed care of the patient rather than simply rendering advice to the ED physician.

When selecting an ED code in this scenario, FPs should be aware that time cannot be used as a factor for code selection because there are no typical times for ED codes in CPT and all three key components required for the code must be met. This is different from the criteria for an established patient E/M visit (99212-99215), where a code can be used if two of the three key components are met and time can be a factor under some circumstances. For example, to code a midlevel ED visit of 99283, the physician must complete an expanded problem-focused history, perform an expanded problem-focused examination, and use medical decision-making of moderate complexity. If the physician's visit meets the first two criteria but includes medical decision-making of low complexity, 99282 should be billed instead of a 99283. Ryan-Niemackl says it is critical that the physician document all three components in the chart fully or proper reimbursement may not be given. For reimbursement, the physician needs to remember that it "doesn't matter what they do; it matters what they document," she says. In other words, payers will consider only what the physician documents in the record in determining the proper payment. In [...]