Wiki Trauma Surgeons in the ER

[Peter Davidyock]

I have found myself with somewhat of a dilema.
I recently took a job coding for 7 trauma/general surgeons.
All of them code initial inpatient hospital visits when they see someone in the ER whether the patient is admitted or not.
This is separate from medicare pts. They seem to have a grasp on the medicare guidelines for ER reporting.

Example:
Pt presents to the ER for a fall. My trauma Dr see's the pt and does a work up.
The disposition reads: released to home w/instructions for yada yada.

They code this visit as 99221

Am I missing something?

 

[mitchellde]

Sounds like they are misinformed on the visit level designation, you cannot submit a claim that is not supported by the documentation this will need to be converted to an ER level, 99281-99285. You do not need the physician to assign this you can convert it for submission. Somehow they have an idea that Mcare patients are different which is incorrect, unfortunately you have the unenviable job of letting them know this cannot be submitted this way. Get ready for extreme resistance.