# Emergency Department consults with Medicare as prime



## Colliemom

With the new Medicare guidelines we understand that we have to bill inpatient consultations using the initial hospital codes. (99221-99223)  We also understand that office consultations will now be billed as new patient visits or established patient visits.

But what happens when a patient is seen in consultation in the ER and he/she has Medicare?  In the past we billed ER consults using codes 99241 - 99245, and the ER as the place of service.  I read somewhere that we should now be using the Emergency Department codes 99281- 99285.  In the past we never used these codes, as we understood these were only for use by the Emergency Department staff.  Is it true that we should now be using these codes, and does anyone know where I can find this in writing?  (multiple sources would be welcome, as we are receiving conflicting information, one source said to use 99201 - 99205 and the ER as the POS.)


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## Walker22

You would use the new or established patient visit codes. If you read them carefully, they are for office OR outpatient use. A patient in the ER that has not been admitted qualifies as outpatient. You would use place of service 23 (ER).


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## MnTwins29

*ER consults - confusing language*

There are three items that address this issue from CMS - MM6740, CR6740, R1875CP.   This is what it states in all of them where it sounds confusing: 

"• If the emergency department (ED) physician, based on the advice of the patient's personal physician who came to the ED to see the patient, sends the patient home, then the ED physician should bill the appropriate level of ED service (ED visit codes 99281 - 99288). The patient's personal physician should also bill the level of ED code that describes the service he or she provided in the ED. If the patient's personal physician does not come to the hospital to see the patient, but only advises the ED physician by telephone, then the patient's personal physician may not bill.

"• If the ED physician requests that another physician evaluate a given patient, the other physician should bill an ED visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an ED visit code."

Hence, I understand the confusion, especially on the second bulleted point, where the "other" physician should bill and ED visit code.  However, I interpred the "request" by the ED physician to mean that the other physician is the only one doing the ED eval - the ED physician is not doing it for that patient.  In the more traditional "consultation" we have used, the ED physician did an evaluation, and he requested a consultation from a specialist.  In that case, if the patient is not admitted the specialist should use the appropriate office/outpatient E/M code.

Hope this makes sense!


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## RebeccaWoodward*

*Use of Emergency Department Codes to Bill Nonemergency Services*

Services in the emergency department may not be emergencies. However the codes (99281 - 99288) are payable if the described services are provided.
However, if the physician asks the patient to meet him or her in the emergency department as an alternative to the physician's office and the patient is not registered as a patient in the emergency department, the physician should bill the appropriate office/outpatient visit codes. Normally a lower level emergency department code would be reported for a nonemergency condition.

If the ED physician, based on the advice of the patient's personal physician who came to the emergency department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of emergency department service. The patient's personal physician should also bill the *level of emergency department code *that describes the service he or she provided in the emergency department. If the patient's personal physician does not come to the hospital to see the patient, but only advises the emergency department physician by telephone, then the patient's personal physician may not bill

*If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code.*

It's my understand that non-emergencies (*alternative* POS to meet rather than the office) are billed with office/outpatient codes.  If it is a true ER visit and the primary care is asked to see this patient, by the ER physician, but does not admit, bill from the ER codes.

http://www.cms.hhs.gov/Transmittals/Downloads/R1875CP.pdf

Starts at page 16


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## Colliemom

MNTwins,

So this sounds like it is open to interpretation. (the second bullet point) Because that word "request" isn't really clarified....it could mean request your specialist to perform the ED visit, and thus bill the appropriate ED services code.  Or the word "request" could mean request your specialist see the patient and provide his/her opinion.  So how you would code depends on your interpretation of this explanation.  

Now I can see why we are getting conflicting information.  My supervisor just emailed me this from another source, the name of which she didn't provide, that seems to imply we should use the ED services codes:

"Consults in the ER.

If you are called to the ER to consult on a patient and you do not admit the patient, use the appropriate Emergency Department Services code (99281 – 99285). "

That's why we are looking for different sources....thank you!

_______________________________________________________________

Rebecca, 

what you are saying seems to support billing the 99281 - 99285, by our specialist in an emergency situation, when the patient is not being admitted.  Thank you for your input.  But just one more question, because this has happened in the past...

A patient, with Medicare, comes into the ED/ER
Our specialist is called down to the ED/ER to provide an ER consult
Our specialist renders his service, makes his recommendations and leaves.
A few hours later, perhaps because the patient's condition worsens, the patient is admitted to the hospital.

Does this effect the code our specialist should bill?  My thinking is that it shouldn't, because at the time the services were rendered the patient was not an inpatient, as he was not admitted until after our specialist had seen the patient.  So we should be billing the appropriate 99281 - 99285 code.  In the past we had problems getting paid for these ER consults by a couple of our carriers, when the patient is admitted after we have seen him/her in the ER.


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## racheleporterwilliams

it's okay to use psych eval codes in ER
however, all evals in ER can combine to equate to the highest level of ER E/M



Katkia222 said:


> With the new Medicare guidelines we understand that we have to bill inpatient consultations using the initial hospital codes. (99221-99223)  We also understand that office consultations will now be billed as new patient visits or established patient visits.
> 
> But what happens when a patient is seen in consultation in the ER and he/she has Medicare?  In the past we billed ER consults using codes 99241 - 99245, and the ER as the place of service.  I read somewhere that we should now be using the Emergency Department codes 99281- 99285.  In the past we never used these codes, as we understood these were only for use by the Emergency Department staff.  Is it true that we should now be using these codes, and does anyone know where I can find this in writing?  (multiple sources would be welcome, as we are receiving conflicting information, one source said to use 99201 - 99205 and the ER as the POS.)


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## RebeccaWoodward*

Our carrier simplified it (somewhat) and follows in line with the link above...


1) Primary care or requested MD see's patient in ER as an *alternative place/Convenience *as opposed to office (I can't think of a time when our providers have done this)-*Bill office/outpatient codes*...(definition of ER is below)

Services in the emergency department may not be emergencies. However the codes (99281 - 99288) are payable if the described services are provided.

Emergency department coding is not appropriate if the site of service is an office or outpatient setting or any sight of service other than an emergency department. The emergency department codes should only be used if the patient is seen in the emergency department and the services described by the HCPCS code definition are provided. The emergency department is defined as an organized hospital-based facility for the provision of *unscheduled *or episodic services to patients who present for immediate medical attention.

2) ER physician requests physician to see patient in ER-(guidelines met for ER visit)No admission-*bill ER code (99281-99285)*

3) ER physician requests physician to see patient in ER (guidelines met for ER visit) and requested physician admits patient-*99221-99223 (AI mod)*


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## RebeccaWoodward*

Katkia,

I want to make sure I have this right in my head...

So...ER physician contacts your provider to see the patient in the ER.  Your provider sees the patient, renders his opinion and leaves.  Few hours later, the patients condition worsens and *your* physician, then, admits the patient?

If your provider saw the patient in the ER and several hours laters, admits the patient...it's my opinion that you could only bill the admission.  My thoughts on this follow the same concept as the office visit and admission to hospital by the same provider, same day.  The office visit is "rolled up" into the admission.

If I've misunderstood and your physician was not the admitting physician but rather another provider admitted the patient...you could still bill for the ER service.

Now...I recently wrote our medical director on this scenario:

Our specialist is contacted by the admitting physician for advice on treatment.  My specialist in turns bills *99221-99223 (POS 21)*, lets say 1-10-10. Several days later (lets say 1-13-10), my specialist admits the patient into *IRC (POS 61), *we bill *99221-99223 with the AI modifier.*

Per our medical director, we can bill for the initial visit and the admission since they are different DOS' and different POS and technically, different types of services, per se.


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## Colliemom

No, in this case another physician admits the patient....after our specialist performed an ER consult.  For some reason a two of our carriers are denying our outpatient ER consultations when the patient later becomes inpatient.


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## Colliemom

BTW - for any others dealing with ER consultation codes and Medicare - I just got back from a CMS Webinar and the final answer was:

If a specialist is asked to see a patient in the ER, and does not admit the patient, the specialist should bill an Emergency Department Services code for the visit. 99281 – 99285


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## RebeccaWoodward*

Katkia222 said:


> No, in this case another physician admits the patient....after our specialist performed an ER consult.  For some reason a two of our carriers are denying our outpatient ER consultations when the patient later becomes inpatient.



And you billed from 99281-99285? and they denied?


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## Colliemom

No, we billed 99244 with the place of service as the ER.  That is how we bill all our ER consults, but every so often we get a denial, and it usually ends up being a patient who was seen in the ER and then later admitted, by someone else.


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## pdege

*POS 23 "Consult"*

How about a consulting physician (Hospitalist) called to the Emergency Department by the E/R doc at 11 pm and the consulting physician sees the patient in the Emergency Department and decides to admit the patient, but the patient is not actually admitted (because perhaps beds were not available before 12AM) as an inpatient until the next calender day. Under the new Medicare guidelines would the consulting/admitting physician bill a code from the 99211-99205 or 99281-99285 series for the outpatient date and then a follow-up 99231-99233 code when the hospitalist rounds the next calender day? Patient was not put in Observation status at any time either, just wasn't admitted until the next calender date.


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## RebeccaWoodward*

Katkia222 said:


> No, we billed 99244 with the place of service as the ER.  That is how we bill all our ER consults, but every so often we get a denial, and it usually ends up being a patient who was seen in the ER and then later admitted, by someone else.




99244 for *2009*, Medicare patients, would be appropriate (assuming consultation requirements are met)...From 1-1-10, I would bill from 99281-99285 if  your specialist has been asked to see a patient in the ER that *does not *result in an admission. (again...we're speaking about Medicare and those carriers that follow Medicare's guidelines)


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## heatherwinters

*ER Codes*

Upon listing to NGS free teleconference yesterday on the subject, and the one they had last week, it is my understanding that if a consult is performed in the Emergency Room you use the ED codes to report your consult, however, if your MD later that day admits the patient, you can only bill for the admit and not the consultation.  There is another upcoming free teleconference dealing with this next week:
*[FONT=&quot]Consultation Code Teleconference [/FONT]*
  [FONT=&quot]Wednesday, January 20, 2010[/FONT]
  [FONT=&quot]11:00 a.m. – 1:00 p.m. ET[/FONT]
*[FONT=&quot]Dial In Number:[/FONT]*[FONT=&quot] 866 837-0303[/FONT]
*[FONT=&quot]Conference ID #:[/FONT]*[FONT=&quot] 49139695[/FONT]


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## dwobig

*ER Consults*

Maybe I am confused, and I don't mean to confuse anyone else, but my question is if the ER Dr calls a surgeon in to the ED for a consultation on a patient, renders his/her opinion but does not admit the patient, we should bill 99281-99285 for the surgeon, correct?  

Then does the ER Dr get paid for his services?  In our ED the ER Dr usually does a complete hx, exam, and runs a multitude of tests, and then calls in the surgeon.  

Would we use the 99281-85 for both physicians?

Thank you,
Debbie


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## heatherwinters

*Emergency Room Care*

It is my understanding that the ER doctor gets paid, and Surgeon gets paid.  According to NGS you bill based on where the visit occurred and the complexity of the visit performed.  They did not say anything about a modifier being needed for both clinicians to get paid.  Again, National Government Services has a free teleconference next week that may be good to listen to.  They also have an extensive question and answer period at the end of the presentation, however, I'd press *1 as early as possible if you have a question because they do not get to everyone during their QA sessions.


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## RebeccaWoodward*

debwobig said:


> Maybe I am confused, and I don't mean to confuse anyone else, but my question is if the ER Dr calls a surgeon in to the ED for a consultation on a patient, renders his/her opinion but does not admit the patient, we should bill 99281-99285 for the surgeon, correct?
> 
> Then does the ER Dr get paid for his services?  In our ED the ER Dr usually does a complete hx, exam, and runs a multitude of tests, and then calls in the surgeon.
> 
> Would we use the 99281-85 for both physicians?
> 
> Thank you,
> Debbie



According to CR 6740, yes.  I, for one, am keeping a close eye on this code range.  I'm going to monitor Medicare's EOB's for any "issues"...


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## jennamiller

*Medicare/consultation coding*

Can anyone tell me what codes we are suppose to use if the documentation for a inpt consult does not meet the 99221-99223 key components? I thought I saw somewhere to use the 99231 & 99232 codes. Can anyone confirm that? I can't seem to find any direction from CMS as to what codes they want used. Thanks!


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## FTessaBartels

*What if you don't meet 99221*

This may depend on your carrier.  WPS has instructed us to use 99499 Unlisted E/M.

F Tessa Bartels, CPC, CEMC


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## cheermom68

*consult*

NGS has advised to use subsequent visits.  However I understand that CMS is supposed to be giving guidance on this very issue in "the near future" (whatever that means to them).


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## danielm2

If after the ER doc treats the pt and bills 99285 the pt is admitted.  Should you bill 99285 in POS 21?


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## leigh73

*consult*

Are you allowed to bill a consult for a Medicare patient?


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## teresabug

Hi Leigh, 
Medicare no longer recognizes CPT 99242-99245 as of 2010. Can you give us the scenario?


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## dorinda05

I see this thread was started back in 2010. Can someone please refer me to the any guidelines on whether this is still accurate for billing ER consultations with the ER CPT codes for 2016?


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