Facility E/M Straightforward 99281

[cfeilner]

Are you able to code for 99281 on the facility side if the patient left after triage? I am unable to locate anything recent guidelines on the CMS website. The latest I was able to find was 2014. I know that commercial plans you can but I need to verify Govt plans and Medicare replacement plans. Thanks!

 

[cfeilner]

99281 vs 99211

For Medicare only patient's that come into the ED but leave after triage, can the facility charge the 99211 instead of the 99281?
Thank you in advance for any insight!

 

[thomas7331]

I am not an expert on ED billing rules, but per my reading of the Medicare regulations, this would not meet the definition of a Medicare covered service. Per the Medicare Benefit Policy Manual, in order to be covered, outpatient "services and supplies must be furnished as an integral, although incidental, part of the physician or nonphysician practitioner’s professional service in the course of treatment of an illness or injury."

It goes on to explain that: "services and supplies must be furnished under the order of a physician or other practitioner practicing within the extent of the Act, the Code of Federal Regulations, and State law. They must be furnished by hospital personnel under the appropriate supervision of a physician or nonphysician practitioner as required in this manual and by 42 CFR 410.27 and 482.12. This does not mean that each occasion of service by a nonphysician need also be the occasion of the actual rendition of a personal professional service by the physician responsible for care of the patient. However, during any course of treatment rendered by auxiliary personnel, the physician must personally see the patient periodically and sufficiently often to assess the course of treatment and the patient’s progress and, when necessary, to change the treatment regimen. A hospital service or supply would not be considered incident to a physician’s service if the attending physician merely wrote an order for the services or supplies and referred the patient to the hospital without being involved in the management of that course of treatment."

Unless Medicare has published an exception to this rule that I'm not aware of, by my reading of this if a patient presents to an ED and leaves before being evaluated by a physician or without direct physician involvement in the triage, this is not a covered service and would not be appropriate to bill to Medicare with either 99281 or 99211.

 

[fami]

Em visit / with chemo inf ser - outpt facility clinic

For Medicare only patient's that come into the ED but leave after triage, can the facility charge the 99211 instead of the 99281?
Thank you in advance for any insight!

Hi,

Question; do you bill 99211- with chemo/ infusion service on the same day at the facility clinic?

Any link to CMS or compliance you have to share?

Thanks,

Fami

 

[thomas7331]

Hi,

Question; do you bill 99211- with chemo/ infusion service on the same day at the facility clinic?

Any link to CMS or compliance you have to share?

Thanks,

Fami

You cannot bill 99211 with infusions. This is from the NCCI manual, Chapter XI:

The drug and chemotherapy administration CPT codes 96360-96375 and 96401-96425 have been valued to include the work and practice expenses of CPT code 99211 (evaluation and management service, office or other outpatient visit, established patient, level I). Although CPT code 99211 is not reportable with chemotherapy and non-chemotherapy drug/substance administration HCPCS/CPT codes, other non-facility based evaluation and management CPT codes (e.g., 99201-99205, 99212-99215) are separately reportable with modifier 25 if the physician provides a significant and separately identifiable E&M service....Under OPPS, hospitals may report drug administration services (CPT codes 96360-96377) and chemotherapy administration services (CPT codes 96401-96425) with facility based evaluation and management codes (e.g., 99212-99215) if the evaluation and management service is significant and separately identifiable. In these situations modifier 25 should be appended to the evaluation and management code.