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Coding Consult: You can get paid for ED services


Medicare isn't that stingy. Here's what you need to know about emergency codes.


Coding Consult

You can get paid for ED services

Medicare isn't that stingy. Here's what you need to know about emergency codes.

A key misconception among coders is that Medicare doesn't allow a primary care physician and an emergency physician to use emergency department services codes (99281-85) for care of the same patient on the same day. However, the Medicare Carriers Manual (Section 15507) specifically instructs carriers to advise physicians that they should use emergency department codes in certain situations when they provide care to—but don't admit—a patient in the ED, even when the ED physician also uses those codes.

Barbara Holley, a coding specialist at the Stuart, FL-based Martin Memorial Medical Group, suggests sending carriers a copy of the appropriate section of the Medicare manual when you resubmit an improperly denied claim.

The key to whether you should code the visit with ED services codes is the intent behind the ED physician's request that you see the patient. "Is the ED physician asking for an opinion?" says Jean Ryan-Niemackl, a compliance analyst for MeritCare Health System, a multispecialty system in Fargo, ND, that includes clinics, hospitals, and physicians. "Or is he asking you to take over care of the patient?"

If the ED physician is asking you to assume care, use the ED codes. Barbara Holley gives the following example of when to use an ED code: An elderly patient with a history of heart disease calls and complains of indigestion and abdominal pain. You direct her to the ED. The ED physician examines the patient, is not sure whether she should be admitted, and asks you to come to the ED to evaluate her. After arriving, you take her history, examine her, and decide not to admit, instead advising the patient to come to the office the next day for tests and blood work.

The ED physician should code the appropriate ED code based on his or her level of involvement in the case, and you should do the same, since you assumed care of the patient. Both diagnosis codes can be the same.

To use a particular ED code, you need to meet criteria for all three key components, and you aren't allowed to use time as a factor. This is different from the criteria for an established patient E&M visit (99212-15), where a code can be used if two of the three key components are met and time can be a factor.

For example, to code a midlevel ED visit of 99283, you must complete an expanded problem focused history, perform an expanded problem focused examination, and use moderate complexity decision-making. If you meet the first two criteria but your medical decision-making is of low complexity, bill 99282 instead.

Ryan-Niemackl says it is critically important that you fully document all three components in the chart. In addition, note that you can't bill any charges if you simply talk with the ED physician via phone. "The primary care physician has to actually come in to the ED," Holly notes. "He can't bill unless there is a face-to-face encounter."

When to code a consultation

If the ED physician is seeking only an opinion from you, you must use one of the consultation codes (99241-45) for an ED visit, Ryan-Niemackl says.

For example, a diabetic patient comes to the ED disoriented and with high blood-sugar levels. The ED physician calls you in to evaluate the patient. To qualify as a consultation, your visit to the ED must meet certain criteria, including what are often referred to as the three R's: The ED physician needs to request your advice and state the reason, and you need to complete a report. Document all three R's in the patient's ED record.

You must also recommend treatment to the ED physician rather than provide it to the patient yourself. For instance, in the example of the diabetic patient above, you might recommend that the ED physician change insulin levels and advise the patient, who has been drinking, to stop using alcohol.

However, if you assume care of the patient and make those recommendations to the patient yourself before sending the patient home, don't use the consultation codes. Instead, use an ED code.

When to use an E&M code

Some private carriers don't use Medicare guidelines and may balk at paying an ED code for both a primary care doctor and the ED physician. In those cases, some coders advise, use the appropriate outpatient E&M codes (99201-15) instead of the ED codes. However, coders who have been successful in using the ED codes recommend trying the ED codes again with private payers if you haven't done so in the past six months. In addition to Medicare's directive on this issue, the CPT manual advises coders to use ED codes when services are provided in the ED.

You can expect higher reimbursement if you've typically used the E&M codes for care of ED patients who are not admitted. For example, for relatively equal examination, history, and medical decision-making levels in Florida, ED code 99283 will pay $61.94 compared to $35.04 for outpatient E&M code 99213. However, a consultation carries the highest reimbursement, with a midlevel 99242 paying $71.05. (The E&M and consultation codes reflect a site-of-service reduction.) Figures in other areas will vary from these amounts.


This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Rd. South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.


Coding Consult: You can get paid for ED services. Medical Economics 2002;17:23.

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