# Follow-up visits



## LTibbetts (Jan 19, 2010)

I am just wondering if I could get some opinions on this. There seems to be some confusion in my office and I want to see what the norm is on this. 
Example: For an ER visit, a patient has cellulitis and comes in for the next 2 days for antibiotic injections. For the follow-ups, there is a minimal exam done. He barely fills out any of the t-sheet that we use for the ER charts and the only physical exam documented is extremely minimal. Can you charge for a level one exam or is it no charge? Since there was an injection done, you need to charge a level one, correct?

Second example: Is a patient that has sutures or an abscess and they are here to get looked at as a follow up to their intital ER visit. The same applies to the amount of dictation supplied, which is minimal and only for the area affected, and no further care is needed. For the sutures, they are not ready to come out for a while yet and for the abscess, the drain is no longer in and it is just to look at it and make sure that it is healing properly. Can you charge for it?

I am trying to find out when you can charge for a level one vist and when it is no charge. What qualifies as an ER no charge visit? There doesn't seem to be a consistency here to the information that I am getting so I thought I would see what you guys think. Anyone?


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## FTessaBartels (Jan 19, 2010)

*Global period*

I do not code for the ER and never have, so my expertise is limited here.

But in general, if you perform a procedure that has a global period (10 days for abscess I&D for example), then routine "postoperative" care during the global period is covered in your reimbursement for the procedure. 

So if a patient came in with an abscess, and the I&D was done by my provider, who charged for that service, I would NOT charge when the patient came back 5 days later for a check-up.  I would code it as 99024 for tracking purposes. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## LTibbetts (Jan 19, 2010)

Ok, thank you. Since the ER has a different doc every day, we still qualify as the "same practice", correct? My immediate supervisor is telling me that if any type of physical exam at all was done, than we are to charge for it, even if it is only the area that was affected.(she is not certified and doesn't have a lot of coding experience, she has only coded ancillary services, and not any ER charts, so I need something to prove this to her if I can find anything).  Do you know of something in writing anywhere that I can give to her that explains the global guidelines for ER procedures? I can find global guidelines, but nothing that specifies ER global coding. Does it matter that we are critical access in this situation?


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## mitchellde (Jan 19, 2010)

Are you billing for the physician or the facility?


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## LTibbetts (Jan 20, 2010)

For the ER's, I only bill the pro fees now.


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## anita carleton (Jan 20, 2010)

Thought I would throw in my 2 cents... When billing for ER visits there are no follow up days. There are no established patient codes, new pt etc. They are considered "new" each time they come through the ER. As long as you are billing for ER phys. that are treating in a hospital based ER then this should apply. For example, You have a patient that comes to the ER each time they are ill due to not having a family physician. These patients are new patients every visit when they go through an ER. You should bill each and every time you treat someone in the ER regardless of what they had done. Hope this helps you! 

Anita Carleton, CPC


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## cjmusser (Jan 21, 2010)

These are my thoughts - it sounds as though the patient came into the ER with an abscess/cellulitis and then is coming back to the ER for follow up injctions/antibiotic treatment.  This patient is using the ER esentially as a clinic.  The guidelines for reporting an E/M with a procdure apply to any place of service - there must be a "significant and separate identifiable service" above and beyond the routine pre and post procedure work associated with the procedure being performed.

A brief inspection of the affected area would be considered "routine pre procedure work".  If it was planned for this patient to come in to get the antibiotic injection I would only charge for the injection and the drug unless there is documentation that supports a level that is "signfiicant and separately identifiable".  

Even though they are different docs each day they are all same specialty and if billing under same tax I.D. # they are all subject to the same global period guidelines.

The issue is that usually patient's don't follow up with the ER PHysicians - they get the initial treatment and then follow up with a PCP.  But if they are coming back for further treatment then the global periods would still apply (unless there is some rule that I have never seen or heard of before)....which is possible! 

Hope this helps and didn't add confusion.
Christina Musser, CPC


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## LTibbetts (Jan 21, 2010)

anita carleton said:


> Thought I would throw in my 2 cents... When billing for ER visits there are no follow up days. There are no established patient codes, new pt etc. They are considered "new" each time they come through the ER. As long as you are billing for ER phys. that are treating in a hospital based ER then this should apply. For example, You have a patient that comes to the ER each time they are ill due to not having a family physician. These patients are new patients every visit when they go through an ER. You should bill each and every time you treat someone in the ER regardless of what they had done. Hope this helps you!
> 
> Anita Carleton, CPC




Thanks, Anita, but i am not sure why you are telling me this. I realize that every patient that comes into the ER is a new patient. My question was about global procedures and policies.


Christina, thank you so much. That makes a lot of sense and helps me a lot! We are a small hospital in a very small town and a lot of our summer patients are tourist, etc, and many of our other patients don't have a PCP and aren't interested in getting one, and when the er doc says "come back in two days so I can check it", they usually do. So thanks again for the clarification


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## cjmusser (Jan 21, 2010)

Hey Leslie,

No Problem - I can understand Anita's point - if the patient's are using it as an ER for every new illness you would be able to code an ER visit which is not respective of new or established.  But in the case you were describing there was a procedure involved and follow up by the ER doc - This is not the norm with ER  - so you have a unique situation - but the rules still apply and if he is taking on the care and doing follow up then the same rules would apply for global days, ect..  If there was not a procedure with global days involved and the patient needed to come back for follow up then you could bill an E/R visit each time unless they were coming back and only a procedure was documented.  You may also want to check on some guidelines - sometimes hospitals will have a differentiation between "urgent care" and ER care - meaning that there is criteria that has to be met to use the ER codes - otherwise the office/outpatient codes are used becasue the patient is using the ER as thier PCP.  Just because the patient is in the ER does not mean that the ER codes have to be used.  99201-99215 are appropriate in some cases as these are not limited to "office".  (This is not official advice - you would have to go by the rules set up at your facility).

Sorry if I confused you more.  I understand where you are coming from - I worked in a rural area for many years!

Christie


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## losborn (Jan 21, 2010)

As a payer, I would have a hard time with the medical necessity of going to an ER for a F/U shot.  A provider (MD or facility) submitting a fair number of these could be in line for an audit.  The -58 might work, but what then of the facility charges?  Is the facility billing for the use of the ED too?

Lin CPC CFE


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## LTibbetts (Jan 21, 2010)

Christie, you actually make a lot of sense and I totally understand where Anita is coming from as well.  I guess I should've explained my situation a little better. I tend to just type what I think sounds right to me which is not always a proper description of what I mean 
We are a small CAH so some rules apply here that wouldn't be the norm for most places. I am considering taking on a new job soon in a bigger hospital that is not a CAH so I really need to learn as much as I can about this situation, regardless, in order to know how to code correctly no matter where I am working. So, thanks again to both of you for all of your help.


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