Wiki Is it ok to bill 99284 and 99285-25 together for ER visit?

[JSHUM]

Hello,
Is it appropriate to code 99284 for the physician charge and 99285-25 plus 93971 for facility charge when the evaluation was done by the PA under the same doctor on the same day at the emergency department? I'm not too familiar with EM level coding for Emergency Department so your input would be appreciated. ED is claiming they can do that because one is a physician charge and one is a facility charge. Also, the level of EM service seems too high as well for a visit concerning if the patient was experiencing a pulled muscle or possible blood clot in a leg. The patient was alert, functioning, and in a non emergency state.

 

[jkyles]

Hi there, if the PA is from the same group, the separate code can't be reported.

Everyone involved in billing ED visits read the E/M guidelines in the CPT manual to gain a clear understanding how to code and report these services. You may need to bring in a consultant if no one is comfortable with pro fee billing.

 

[JSHUM]

In the case PA is from the same group, would it be more appropriate to bill just 99284 and not 99285-25, the facility charge?

 

[thomas7331]

Hello,
Is it appropriate to code 99284 for the physician charge and 99285-25 plus 93971 for facility charge when the evaluation was done by the PA under the same doctor on the same day at the emergency department? I'm not too familiar with EM level coding for Emergency Department so your input would be appreciated. ED is claiming they can do that because one is a physician charge and one is a facility charge. Also, the level of EM service seems too high as well for a visit concerning if the patient was experiencing a pulled muscle or possible blood clot in a leg. The patient was alert, functioning, and in a non emergency state.

It is appropriate to code a different level for the professional charge than for the facility charge - the guidelines are different for facilities which are coding based on resource utilization rather than on professional services which follow E&M guidelines. The ED is correct in saying they can do this.

Your level for the EM service should be based on the level of the history, exam and medical decision making. I don't agree with you that this patient's situation was not emergent just given that they were alert and function - a blood clot is potentially life-threatening condition. In any case, it's not really up to the coder to determine whether or not the patient was in an 'emergency state' - only the providers can make that determination. Best to just following the E/M coding guidelines and code based on the documentation.

 

[amyjph]

I agree with Thomas. The facility can differ from the pro fee charge. I also agree that it's not up to a coder to make a clinical call like that, you code according to the documentation.

 

[sls314]

In the case PA is from the same group, would it be more appropriate to bill just 99284 and not 99285-25, the facility charge?

There will always be a facility charge for an ER visit.

The physician bills for their time and professional expertise. The facility bills for all of the resources used during the visit - the room, nursing, equipment, supplies, etc.

As Thomas mentioned, the level of the facility and professional ER fee doesn't have to match, and often won't.