# E&M coding in the ER



## twizzle (Aug 20, 2014)

I need some really constructive and accurate advice regarding coding in the ER.
Several scenarios....my doctor(say a cardiologist) is asked to see a patient in 
the ER for a consult;he does the consult and the patient goes home.
My thinking is that I bill an ER consult  9928_ and POS ER. 

Same scenario but the patient is then admitted to OP observation (same day). Do I bill an OP consult and use POS ER? Or patient admitted as IP? I don't think I would bill an IP consult and POS ER.

What about a patient who has an ER consult by my doc, then goes for surgery urgently the same day, and ends up being admitted the following day as an IP?
I think that an ER consult would be billed (with POS ER) because that is effectively saying that the patient is in the ER that day and discharged from the ER.

There are so many scenarios that it is difficult to cover all of them. My work colleagues (and manager) all have different opinions anyway.

What I really need to know,(or at least know where to find the information in black and white) is the protocol for billing consults in the ER (not by the ER physician) by anyone who sees a patient in the ER. CPT codes and POS are all I need.

I look forward to advice but I don't want replies saying "I think this is what you do"..."this is my opinion". Just facts please. I know there are a few well-informed coders/managers out there who can give me an answer and I look forward to your input.


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## joykaye8 (Aug 20, 2014)

You would bill for the consulting physician from "Office or Other Outpatient Consultations," which includes code 99241 through 99245.  Under the guidelines for this section, it specifically notes, "The following codes are used to report consultations provided in the office or in an outpatient or other ambulatory facility, *including hospital observation services*, home services, domiciliary, rest home, or *emergency department*..."  Both the ER and observation setting are considered to be outpatient settings, and thus are coded accordingly.


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## mitchellde (Aug 20, 2014)

In the Medicare manual, there is a section that covers ER visits.  If your provider is called into the ER to see the patient by the ER provider then you use ER visit levels and POS ER.
As far as the patient being admitted to observation, if your provider saw the patient in the ER prior to the order for observation then the answer is the same, ER level and ER POS.  However if your provider saw the patient after the order was written for observation status then even though the patient may still physically be in the ER they are still an obs patient so you use the 99201-99215 codes with outpatient POS.  
If your provider sees the patient after the inpatient order is written the you May bill initial inpatient with inpatient POS.
Now if your provider is the one admitting the patient to obs, then you do not bill the ER visit you roll everything into an obs admit level with POS 22, same with inpatient with POS 21.
If your provider sees the patient in the ER and then admits them post surgery then again you roll the ER complexity to the inpatient initial.


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## twizzle (Aug 20, 2014)

Thank you Debra and Joy for your input. Of course, I may not know if orders have been written for admit to OBS or IP, in which case I will have to claim ignorance and bill an ER consult.
So I am right in using the overall assumption that if the patient goes nowhere apart from home having spent a period of time in the ER, I will bill a 9928_ and POS ER. If I know the patient went elsewhere I will bill the appropriate OP or IP consult code and POS, even if the transfer was the following day...right?


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## mitchellde (Aug 21, 2014)

Actually you will need to know if the patient has been admitted to either inpt or obs prior to your provider seeing the patient.  Location of the patient is not the determining factor.  Any bed can be an obs bed or an inpt bed, so just because the patient is still located in the ER does not mean the POS is the ER.  This should be included in the providers documentation when they perform the consult.


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## twizzle (Aug 21, 2014)

mitchellde said:


> Actually you will need to know if the patient has been admitted to either inpt or obs prior to your provider seeing the patient.  Location of the patient is not the determining factor.  Any bed can be an obs bed or an inpt bed, so just because the patient is still located in the ER does not mean the POS is the ER.  This should be included in the providers documentation when they perform the consult.



Your help is much appreciated. I also think that the same principle applies to procedures performed prior to IP or OP admit. I had a situation where a procedure was performed prior to admit..it was a post-operative infection necessitating a return to the OR and then IP admit; it denied for no auth because it was billed as IP even though, technically the patient went to the OR from the ER. I think IP was the correct way to bill it. The hospital will certainly bill it at as an IP encounter.
Am I right?


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## margiemed117 (Aug 24, 2014)

You would be amazed at the amount of information you will find in your CPT as far as guidelines are concerned! 
This is where I get almost all of my questions answered! Best of luck to you!


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