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Emergency Department

  1. Please define correct coding for an ER service by a consulting provider, when requested by an ER provider.

    Answer:
    CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, 30.6.11(A) (1 MB) indicates that “Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department.” Further, 30.6.11(F) indicates “If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code.” Updated 8/29/2017
     
  2. NGS guidance for CPT code 99285 states, “The documentation should support that the presenting problem requires the immediate attention of a physician for problems of high severity that pose a significant threat to life or physiologic function." Can a visit be billed as 99285 when the presenting problem is not of high severity, or life-threatening?

    Answer:
    The presenting problem sets the direction for the level of history, examination and MDM that is medically necessary. A comprehensive history and examination may be “appropriately done” but the medical necessity for these services must correlate to the patient’s clinical status on presentation. Updated 6/9/2017
     
  3. Please clarify coding for minor procedures in the ED. Is an E&M service considered separate from the procedure in this circumstance?

    Answer:
    E&M services in the ED are performed to evaluate the patient’s presenting problem by obtaining a history, performing an appropriate examination and deciding on a medically necessary plan of care. When that plan of care includes a minor procedure (e.g., laceration repair), an E&M service may be billable, but circumstances will dictate the performance of a truly separate E&M service with a modifier 25. Examples of two different circumstances:
    • A patient presents with a laceration of the left hand and a painful and swollen left wrist, both incurred through a fall that was precipitated by an episode of acute vertigo. The patient also has a history of osteoporosis. The patient’s clinical history and HPI supports the need for a physical examination, including a neurological evaluation, and performance of a CT scan of the head, X-ray study of the left wrist and repair of the laceration. The care rendered supports a separately identifiable E&M service, since the provider has performed additional components of care and medical decision making, beyond the laceration repair.
    • A patient presents with a laceration of the left hand, incurred through a fall from slipping on water in the kitchen. The provider assesses the laceration and performs a simple repair. In this scenario, there is no separate service beyond the laceration repair, and the visit would not warrant billing for a separately identifiable E&M. Updated 6/9/2017
       
  4. Can two or more providers bill the ER codes on the same date of service within the same encounter?

    Answer:
    An ER code may be billed by more than one provider, as long as their Medicare specialties and NPIs are different. This can occur when a patient is seen in the ED by both the ED physician and the patient’s personal physician, or in a circumstance in which the ED physician requests that another physician evaluate a given patient. Updated 6/9/2017
     
  5. What is the appropriate coding for a consultant service in the ED (e.g. psychiatry).

    Answer:
    As above, a consultant in the ED would bill for ER services using the ED series of CPT codes (99281-99285), with code selection based on the scope of medically necessary services performed. Updated 6/9/2017
     
  6. Please clarify appropriate billing for patients who have been admitted to a psychiatric service, but now in an extended ED stay, awaiting a bed.

    Answer:
    If the patient has been formally admitted to inpatient status (POS 21) and is waiting in the ED for psychiatric bed assignment, then physician services can be billed with inpatient E&M codes (99221-99223, 99231-99233).

    If the patient remains in outpatient status (POS 22), an order for observation will allow the primary care physician to bill for services using the observation codes (99218-99220, 99224-99226). Care by consultative providers can be billed using outpatient E&M codes (99201-99205, 99211-99215). Updated 6/9/2017
     
  7. Does the concept of a “new patient” or “new problem” apply to patients treated in the ED?

    Answer:
    The concept of “new” vs. “established” patients does not apply in the ED. All ED patients, and their presenting problems, are considered as new, regardless of the patient’s history or the examiner’s prior experience with the patient. Updated 6/9/2017

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