emergency room E&M visit - surgeron practice

kdr4079

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Hello,

I am on day 2 of my employment with a hand surgeron practice. This is a new field for me to code and I've already run into a coding question.

A doctor saw an ER patient. He charged 99283 which, according to documentation, seems appropriate. However, He also indicates he wishes to charge cpt 99050. I feel that this is incorrect because the code description states that the patient is seen "in the office". My question is--where can I find documentation to back up my theory? Before I go to this physician (as a brand new employee, AND being brand new to surgery coding) I'd like to have documentation supporting my determination that he cannot charge 99050 when he saw this pt. in the ER.

Thanks to anyone who can help! :)
 

Lisa Bledsoe

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For one, simply show the doctor the definition of 99050 in CPT, which clearly states "in office". Second, I would be concerned about the ED code - unless your doctor was the only one who saw the patient in the ED. More often then not, the ED doc has already submitted his/her claim and yours will be denied as duplicate, even though the NPI is different. I try to get my docs to use codes other than ED codes if at all possible.
 

grahamki

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I am kinda of confused. You stated that your doctor seen the patient in the ER? Did the patient go to the ER and seen the ER physician and then ER physician consult your doc to come and see the patient? If so then shouldn't this been a consult code 9924? instead of an ER code?
 

smithls

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Er e&m's

Can a hospital ER department charge 99283 and the ER provider, who is contracted with the ER department, charge 99284 for the same patient, same day, same time, same dx?
 

LLovett

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F. Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting
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. If the criteria for a consultation are not met and the patient is discharged from the Emergency Department or admitted to the hospital by another physician, the physician contacted by the Emergency Department physician should bill an emergency department visit. If the consulted physician admits the patient to the hospital and the criteria for a consultation are not met, he/she should bill an initial hospital care code.

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

The above information is from page 60 in the above linked manual. Before that is all the info about consultations.

Laura, CPC, CEMC
 

lisigirl

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I agree that if you show the MD the description of code 99050, that should be enough to support the fact that you can't bill for this when the place of service is the ER! I'd be shocked to hear insurance plans pay for that anyway.

To add to what everyone else wrote, he should not be billing the ER cpt codes unless he is the ER physician (because the ER physician has probably already billed them). If consulted, bill the consult codes. If not a consult, I would bill the new pt/est pt codes (99201-99215) or, if patient was admitted, I would bill a subsequent hospital visit (99231-99233).

I would assume it was a consult unless your doctor directed the patient to go to the ER and then he showed up to see him there (which is sort of what I think because he's trying to get away with billing 99050...lol). If that is the case, bill an office/outpt visit code.

Lisi, CPC
 

LLovett

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http://www.wpsmedicare.com/part_b/policy/phys021.pdf

Does anyone have documentation stating only one ER E/M can be reported in one day?

The direction I have been given by WPSMedicare, states multiple providers can bill the ER E/M codes on the same patient on the same day. I have posted the link for the NCD on this issue.

If someone has something in writing that contradicts this please post it. I will take it back to WPS for further clarification.

Thanks

Laura, CPC, CEMC
 

pamtienter

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Our clinic is next door to the hospital and our docs go over and see patients in the ER too, if they're called. Our docs will also bill an ER visit (if it's not an admission) and we haven't had problems with it.
 

RebeccaWoodward*

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Laura,

You are correct. You validated this in your previous post.

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. If the criteria for a consultation are not met and the patient is discharged from the Emergency Department or admitted to the hospital by another physician, the physician contacted by the Emergency Department physician should bill an emergency department visit. If the consulted physician admits the patient to the hospital and the criteria for a consultation are not met, he/she should bill an initial hospital care code.
 

LLovett

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Thank you both, I appreciate it. I have seen on other posts the same comment, that only ER docs can bill these codes.

This is the direction we are pointing a lot of providers in and I want to be sure it is correct.

Thanks!

Laura, CPC, CEMC
 

lisigirl

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I apologize for the mis-information, I was once told that only one physician per day could use codes 99281-99285 and I never heard otherwise. This really is good to know though. We have WPS Medicare as well so I am going to let our coder for Trauma know about this.

Does anyone know if the following could be a problem though - we're a level 1 trauma center so when a trauma comes in, our trauma team is activated. They end up seeing the patient as well as the ER physician. Can both physicians bill the ER codes (they'll probably have the same dx as well)?

Thanks!

Lisi

My answer to the original question sticks though, don't bill the 99050 - LOL.
 

RebeccaWoodward*

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Lisi,

I wanted to share something regarding the ER CPT codes. You're comment regarding using outpatient office visits for a non-ER physician was not incorrect. There is a spin to this...

Your Comment.
"To add to what everyone else wrote, he should not be billing the ER cpt codes unless he is the ER physician (because the ER physician has probably already billed them). If consulted, bill the consult codes. If not a consult, I would bill the new pt/est pt codes (99201-99215) or, if patient was admitted, I would bill a subsequent hospital visit (99231-99233)."

I can not take credit for the information below. Another coder (w/ many other credentials) that I follow regularly posted this article on another site. I felt I needed to add this information to this thread.

How to Bill an E/M Service Provided by a Non-Emergency Medicine Provider Who:
a) Did Not End Up Admitting the Patient, and
b) Was Not Consulted


Per CPT®, any physician can bill an ED E/M code, but if two physicians both see a patient in the ED, and one of them is an Emergency Medicine specialist, CPT® (in the summer 1995 and January 2002 CPT® Assistants) says that the EM provider should be the one billing the ED code and the other physician will either bill an admission, consult, or an office/other outpatient visit code. Per the January 2002 CPT® Assistant: “for any single ED patient visit, only one physician can report an ED E/M code.”

So for those payers that give no specific direction that contradicts established CPT® coding instruction, a code from the New/Established Office/Other Outpatient Services range (99201-99215) should be billed as appropriate for a non-ED provider seeing the patient in the ED

1. if the patient was already seen by an ED provider, and
2. if the second provider
a) is not admitting the patient, and
b) was not consulted (usually they were just asked to come manage/treat
the patient)

Medicare, however (emphasis mine), gives different instruction that contradicts CPT’s direction. They say that the provider contacted by ED to see a patient (but who was not consulted for an opinion and does not admit the patient) should bill the encounter using one of the ED E/M codes:

Medicare Claims Processing Manual
Chapter 12 - Physicians/Nonphysician Practitioners
F. Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting
“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. If the criteria for a consultation are not met and the patient is discharged from the Emergency Department or admitted to the hospital by another physician, the physician contacted by the Emergency Department physician should bill an emergency department visit.”

Presumably (but not entirely certain based on Medicare’s manual instruction), the ED physician would still bill an ED series code to Medicare as well if they performed an E/M service prior to the second provider’s service, as Medicare does sometimes allow two providers to bill ED codes for the same patient on the same day. That’s not to say that a particular Medicare carrier doesn’t have an edit that will try to deny the charge on the front end. They may, and an appeal may be necessary to get paid for both services. To improve chances of reimbursement, the documentation should reflect the medical necessity of both encounters.



To be fair on both sides (CPT versus Medicare), I thought it was important to share both views since there could be a carrier that does not follow Medicare's ideology.
 
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mitchellde

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I apologize for the mis-information, I was once told that only one physician per day could use codes 99281-99285 and I never heard otherwise. This really is good to know though. We have WPS Medicare as well so I am going to let our coder for Trauma know about this.

Does anyone know if the following could be a problem though - we're a level 1 trauma center so when a trauma comes in, our trauma team is activated. They end up seeing the patient as well as the ER physician. Can both physicians bill the ER codes (they'll probably have the same dx as well)?

Thanks!

Lisi

My answer to the original question sticks though, don't bill the 99050 - LOL.
I have read all of these posts and I am wondering if we have different issues here. You work for a trauma center, so my question is are you billing for the facility or the physician? In some of the posts it sounded like physician and in some like this one it sounds like facility. A facility can and should bill for every encounter with the patient. So if a patient comes to the ER multiple times they will have an ER E&M for each individual encounter, using a 27 modifier on the second and subsequent and a G0 condition code.
I hope I did not add mud to the water here!
 

LLovett

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Very interesting, thanks for posting that Rebecca.

I will have to watch for this as many times the patients affected by this, in our practice, are not covered by Medicare.

Laura, CPC, CEMC
 

RebeccaWoodward*

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Debra,

I'm provider based. It's not often, but there are times when the ER physician and my physician both submit ER visits. The scenario I posted was applying to our setting.

Laura,

Me too...I tend to pull from CMS guidelines before CPT Assistant. This was a reminder to me that I need to consider both.
 

lisigirl

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Rebecca,

Thank you so much for the information. Now I know I'm not completely losing my mind! However, I didn't know Medicare actually allowed multiple ER E/M bills on the same day. Like Laura, we have WPS Medicare (until Noridian takes over as our MAC) so we should be able to bill this way as well.

Debra,
I am in a provider setting. We're located on the hospital campus though and the hospital is a level one trauma center (so our physicians get called for trauma activations). I'm only coding the professional services.

Thank you everyone for this great info!

Lisi
 
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ER department E/M for facility and physician

Can a hospital ER department charge 99283 and the ER provider, who is contracted with the ER department, charge 99284 for the same patient, same day, same time, same dx? I have been seeing this a lot lately and would like to know if this is correct, because I would think that it isn't.
 

mitchellde

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Can a hospital ER department charge 99283 and the ER provider, who is contracted with the ER department, charge 99284 for the same patient, same day, same time, same dx? I have been seeing this a lot lately and would like to know if this is correct, because I would think that it isn't.
Yes the facility charges the level of service the matches their facility specific guidelines/tool for E&M charges and the provider charges the level of service that matches his documentation according to either 95 or 97 guidelines, and they will most times be different levels.
 

kmcdanel

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ER Billing

According to the new medicare guidelines, if the patient is a medicare patient, you must use the ER codes. if the patient is not, you would use office visit/outpatient consult codes.
99241-99245. Billing 99050 would not be appropriate.
 

hawkinsj

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For one, simply show the doctor the definition of 99050 in CPT, which clearly states "in office". Second, I would be concerned about the ED code - unless your doctor was the only one who saw the patient in the ED. More often then not, the ED doc has already submitted his/her claim and yours will be denied as duplicate, even though the NPI is different. I try to get my docs to use codes other than ED codes if at all possible.
I do not agree with you on the ED visit. I code for a Hospitalist practice and am in their Compliance division. We see ED patients all the time for consults, admits and clearing/discharging to home or another facility. Yes the ED doc bills his code as do we but we have ID's that are tagged to our specialty as would a surgeon. The payer can clearly see by the ID number and by our billing that we did a consult etc. They are allowed to bill this, we are paid on every claim, no problem.

Janet
 
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