# ED Visits multiple days in a row?



## ardithch (Mar 1, 2016)

We have a common situation where the patient is in the ED for multiple days because a bed is not available in the hospital. The patient's status is not changed to observation or inpatient, before discharged from the ED 3-4 days later. Can the physicians/specialists who see the patient bill ED visits each day with POS 23 (99281-99285?) According to CPT guidelines, ED E/Ms are for new or established patients; however, I am concerend that the subsequent documentation will not support an ED visit.

1) What is recommended to bill in this scenerio for the subsequent visits? One coder is stating an established E/M code (99211-99215); however, the insurances don't want to pay this with the 23 POS.

2) Does anyone have a reference for exactly what is supported in each level of ED visit aside from the CPT manual?

Thanks!
Ardith, CPC, CGSC


----------



## CodingKing (Mar 1, 2016)

I think you are going to have a hard time justify keeping a patient in ER status for 4 days. They either meet the criteria of Observation, Inpatient or should be discharged. I don't believe bed availability is sufficient for not admitting the patient, especially considering its the status not the location that is important.


----------



## ardithch (Mar 1, 2016)

Thank you for your reply. Our issue is that these are usually Psyche patients who are held in the ER when a Psyche bed is unavailable.  Is there any reference material that you know of for coding follow up visits in the ER?


----------



## mitchellde (Mar 1, 2016)

ardithch said:


> Thank you for your reply. Our issue is that these are usually Psyche patients who are held in the ER when a Psyche bed is unavailable.  Is there any reference material that you know of for coding follow up visits in the ER?



Was an order written for inpatient admission, and then no bed available?  If so then the patient is considered to be an inpatient from the time the order is written without regard to where exactly in the facility the patient physically is put.  So if the patient is still in the ER with an order for inpatient, then it is inpatient status at that time.


----------



## ardithch (Mar 1, 2016)

Thank you for your input!!


----------



## melbiv (Mar 2, 2016)

Our small hospital holds psych patients in the ER for multiple days waiting for an available bed in a different facility.   It is especially hard 
to find a psych bed for a patient with medical diagnoses.   We have only been charging one ER facility level and one ER pro fee for the entire
stay.   I would love to hear a different solution to this problem.


----------



## CodingKing (Mar 2, 2016)

melbiv said:


> Our small hospital holds psych patients in the ER for multiple days waiting for an available bed in a different facility.   It is especially hard
> to find a psych bed for a patient with medical diagnoses.   We have only been charging one ER facility level and one ER pro fee for the entire
> stay.   I would love to hear a different solution to this problem.



Charging one fee sounds about right. Now that i really think about it if you are seen in the ER at 11PM and it spans past midnight you cant bill more than 1 E&M so i don't see how this would be any different if it spanned more than just 1 midnight.


----------



## melbiv (Mar 4, 2016)

Thanks everyone.   Because of our remote rural location we are keeping some psych patients 2+ days in the ER while finding an available bed.

I'm on the look out for the correct way to bill these accounts but for now I believe one facility level/one pro fee is our only option.


----------



## lnelms (May 11, 2016)

One ER visit is all you can bill.  It has to be billed with date of service of when patient entered the ER.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1151CP.pdf


----------

