# Emergency room date of service



## hethcl (May 11, 2015)

Looking for feedback as to what date of service you use for professional ED billing. If patient arrives at 10pm and work up is begun but a procedure (say lac repair) is done after midnight at 2am what service date to you bill? Would you bill everything under the date they arrived, everything under the date they discharged, or bill the E&M under the first date (arrived) and the procedure under the second date because it was done after midnight?

Thanks for your thoughts.


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## jademound (May 11, 2015)

*One professional fee per encounter*

Only one professional fee is allowed per ED encounter, and the procedure is the one that would be coded in this instance. Go with the date that the procedure is done as that is what you are coding. I hope this helps.


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## hethcl (May 11, 2015)

*one professional fee per encounter*

That is incorrect, if provided and properly documented, both the ED E&M and the procedure can and should be reported. There are many times in which more than one professional fee is submitted in the professional ED setting. Example, patient that is intubated, central line placed, and critical care provided/documented. You would have 3 professional fees.


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## sswisher (May 11, 2015)

Here is the CMS guidance:  

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2361CP.pdf

180.6 ? Emergency Room (ER) Services That Span Multiple Service Dates
(Rev. 2361, Issued: 11-25-11, Effective: 01-01-12 and 04-01-12, Implementation; 04-02-12)
Emergency room (ER) services provided by hospital outpatient departments (OPPS & Non- OPPS) should be billed in the following manner:
? Emergency room services are reported under the 045x revenue code
? The line item date of service for the ER encounter is the date the patient entered the ER
even if the patients encounter spans multiple service dates
? For all other services related to the ER encounter (i.e., lab, radiology, etc) the line item date of service reported is the date the service was actually rendered


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## hethcl (May 18, 2015)

Thanks for the info. I do have this but it speaks to the facility billing with revenue code etc...

On the professional side, do you believe that this indicates the professional billing should be split if the patient came in at say 10pm and the eval started and at 1am say a suture repair was done that we should bill the E&M service as day 1 and the suture repair with the next day?

Thanks for your input.


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## sswisher (May 20, 2015)

I would treat the professional billing the same as the facility (in other words, I would not split it into separate days).  Here's my MAC's guidance.  Hope it helps:

https://www.noridianmedicare.com/provider/updates/docs/CAH_QandA.pdf

Q16. If we have patient present to the emergency department close to midnight and continue services into the next day then come in later that day, would we need to include this all on one bill due to the service dates, or should the ER admission be only for the date it occurred. Would the Professional fee and facility fee be billed as the admission date or the discharge date? 
A16. All services for the same date of service need to be on one claim, so these services should be billed together on one claim. Use the date the emergency room service was initiated as the line item date of service for that service for both the facility and the professional charges. Example: Patient presents at 10:30 p.m. on 1/2/12, and receives evaluation and management (E&M) services that last until 4:00 a.m. Patient returns at 8 p.m. on 1/3/12. The claim from through date of service would be 1/2/12- 1/3/12. The first E&M service would be shown with line item date of service 1/2/12 (even though services extended over into 1/3/12), and the second service would be shown with line item date of service 1/3/12. All other services provided during these visits would be listed under the line item dates they were provided.


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## hethcl (May 20, 2015)

Thanks for you input/information again What I am trying to find out, is if other professional ED coders split out a procedure that may have occurred after midnight for a patient that arrived before midnight. Our compliance is telling me we have to bill the E&M on the date of arrival but the suture repair (done after midnight) with the service date of the next date. To me, this is splitting out the overall ED encounter and I was just curious as to how others do this.


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## sswisher (May 20, 2015)

The Noridian document addresses your question directly:  "Use the date the emergency room service was initiated as the line item date of service for that service for both the facility *and the professional charges*."  Note that Noridian uses the term "professional charges", which is inclusive of both e/m's and procedures. 

The only portion of the ER visit that gets billed based on the actual calendar day rather than date of registration are non-ER services such as lab and radiology.   

At my facility our coders do not split the e/m from the procedure and do not assign them different dates of service even if they occurred during different calendar days (ie spanned a midnight). We also use a large outside coding company that similarly does not split the e/m from the procedure.  

I would explain to compliance that the date of service is used rather than the day of procedure because in the ER there are many visits that span midnights (as opposed to clinic visits for which every day is a discrete episode of care).  Ask them for CMS documentation that would contradict the Noridian Q&A.  If they provide it, please link it here.


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## hethcl (May 21, 2015)

Thank you for confirming my thoughts. It's nice to know I am not alone Now I just need to convince others.


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## tkgood2 (Jun 12, 2015)

*Documentation for Visits Spanning 2 calendar days*

I have followed this thread and agree that the billing should be dated the initial date of service which is how we bill.  The problem we are having is the documentation.  The ED provider will document his date for the date he actually saw the patient.  For example, patient presents at 11pm on 6/2/15 and isn't seen until 2am on 6/3 so the note is dated 6/3.  We are being denied for incorrect date of service when documentation is requested. We have looked into this issue and have found supporting evidence that the provider should indeed document the date of service he/she actually saw the patient.  Any suggestions on how to handle this situation?
Thanks!


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## sswisher (Jun 13, 2015)

Yes, the provider should document the time/date patient was first evaluated.  This notation should not be tied to the date of service for billing purposes.

On our EMR, the patient is registered by date/time of arrival.  The provider has a button to click when patient is first seen, which documents the initial evaluation time and lets us report "door to provider" times for HCAHPS.  This button has no effect on the billing date of service.

When we were on paper (T-sheets) the patient sticker had the date/time of registration and the encounter number.  The provider would make a written notation as to when patient was first seen.  Again, this had no impact on the date of service for billing purposes.

So patient registers 6/13 at 2355 and is seen 6/14 at 0015.  Official date of service for billing is 6/13.  Documented date of initial provider evaluation is 6/14.


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