# ER vs. Observation please help!



## samantha Martel (Dec 1, 2011)

we have been having trouble getting reimbursed when we see a pregnant patient in the ER for things like vaginal bleeding or any signs of pre-term labor.  We are not normally the first physician to see the patient.  should we be billing ER, observation, consultant, or office visits?


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## btadlock1 (Dec 2, 2011)

samantha Martel said:


> we have been having trouble getting reimbursed when we see a pregnant patient in the ER for things like vaginal bleeding or any signs of pre-term labor.  We are not normally the first physician to see the patient.  should we be billing ER, observation, consultant, or office visits?




See: http://www.supercoder.com/articles/...ntifying-consultations-vs.-outpatient-visits/

Hope that helps!


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## mitchellde (Dec 2, 2011)

Brandi,
That article is 12 years old and the information has changed.  Per CMS if you are called to the ER by the ER physician then your doc will also use the ER E&M levels.  Observation is used only when the physician has written an order to admit to observation.  Any bed in the facility can be an observation bed, but it takes a physician order in the chart to make it so.  An Office level would be use in the ER if the patient was never registered as an ER patient and not attended to by the ER doc but was in the ER at the instruction of your doc to be seen there by your doc.  This is all in the revised CMS manual of 2010.


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## ajs (Dec 2, 2011)

mitchellde said:


> Brandi,
> That article is 12 years old and the information has changed.  Per CMS if you are called to the ER by the ER physician then your doc will also use the ER E&M levels.  Observation is used only when the physician has written an order to admit to observation.  Any bed in the facility can be an observation bed, but it takes a physician order in the chart to make it so.  An Office level would be use in the ER if the patient was never registered as an ER patient and not attended to by the ER doc but was in the ER at the instruction of your doc to be seen there by your doc.  This is all in the revised CMS manual of 2010.



Yep you are right - here is the actual info from CMS.  I think many of us have been operating under the assumption that the ER E/M code were for ER docs.  Some insurance carriers look at it that way too, but CMS definitely changed their position a while back:

"E. Physician Billing for Emergency Department Services Provided to Patient by Both Patient's Personal Physician and Emergency Department Physician
If a physician advises his/her own patient to go to an emergency department (ED) of a hospital for care and the physician subsequently is asked by the ED physician to come to the hospital to evaluate the patient and to advise the ED physician as to whether the patient should be admitted to the hospital or be sent home, the physicians should bill as follows:
• If the patient is admitted to the hospital by the patient's personal physician, then the patient's regular physician should bill only the appropriate level of the initial hospital care (codes 99221 - 99223) because all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The ED physician who saw the patient in the emergency department should bill the appropriate level of the ED codes.
• 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.

F. Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting
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."


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