# ER Physician charges



## SSweetland (Nov 11, 2008)

If a patient has stitches put in by the emergency room physician (who is an employed physician by the hospital) and then visits one of our clinics to have them removed. Is a clinic physician (employed physician) allowed to charge or is this bundled due to both physicians being employed by the hospital. The ER physician never works in the clinics, he strictly is employed for the Emergency Room. Thanks
Sheila Sweetland, CPC


----------



## FTessaBartels (Nov 12, 2008)

*Same practice, Different Specialties*

The global period applies to the same physician, or any other physician in the same practice, *same specialty*. 

*If *the second visit is with a physician of a *different specialty*, then that visit is billable. *HOWEVER* ... there is no procedure code for suture removal, unless it's done under anesthesia ... you would code the E/M visit only. 

F Tessa Bartels, CPC, CPC-E/M


----------



## jhambng (Nov 12, 2008)

F Tessa,
I have a follow-up question to your response.  If an ED physician performs a sutured skin closure and the patient returns to the same ED (all providers under the same contracted group), can the facility charge for the suture removal visit?  I understand this is not allowed in the office setting, but I wasn't sure about the ED.

Thanks.


----------



## ptrautner (Nov 13, 2008)

Depends on the policy, our policy is if it was placed in our e.d. the removal is free(considered part of the original procedure).


----------



## FTessaBartels (Nov 13, 2008)

*No charge for suture removal*

I don't code for ED, but I agree with Pat.

F Tessa Bartels, CPC, CPC-E/M


----------



## maudys (Nov 17, 2008)

*transfer of care for global period*

you can find this at MCM (medicare carrier manual) subsection 4822.A.2 and states (i have pasted it directly from the manual) :

"Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;

*III. Billing Requirements for Global Surgeries

To ensure the proper identification of services that are, or are not, included in the global package, the following procedures apply.

*A. Procedure Codes and Modifiers
Use of the modifiers in this section apply to both major procedures with a 90-day postoperative
period and minor procedures with a 10-day postoperative period (and/or a zero day postoperative period in the case of modifiers â€œ-22â€� and â€œ-25â€�).

*1. Physicians Who Furnish the Entire Global Surgical Package
Physicians who perform the surgery and furnish all of the usual pre-and postoperative work bill for the global package by entering the appropriate CPT code for the surgical procedure only.
Billing is not allowed for visits or other services that are included in the global package.
*2. Physicians in Group Practice
When different physicians in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group. The physician who performs the surgery is shown as the performing physician. (For dates of service prior to January 1, 1994, however, where a new physician furnishes the entire postoperative care, the
group billed for the surgical care and the postoperative care as separate line items with the appropriate modifiers.)
*3. Physicians Who Furnish Part of a Global Surgical Package
Where physicians agree on the transfer of care during the global period, the following modifiersare used:
• â€œ-54â€� for surgical care only; or
• â€œ-55â€� for postoperative management only.

Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.
Providers need not specify on the claim that care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field/free text segment on the claim form/format. Both the surgeon
and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary's medical record.
EXCEPTIONS:
• Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate evaluation and management code. No modifiers are necessary on the claim.
• If the transfer of care occurs immediately after surgery, the physician other than the surgeon who provides the in-hospital postoperative care bills using subsequent hospital
care codes for the inpatient hospital care and the surgical code with the â€œ-55â€� modifier for the post-discharge care. The surgeon bills the surgery code with the â€œ-54â€� modifier.
• Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of office visit code. The physician who performs the emergency room service bills for the surgical procedure without a modifier.
• If the services of a physician other than the surgeon are required during a postoperative period for an underlying condition or medical complication, the other physician reports
the appropriate evaluation and management code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.


----------



## SSweetland (Nov 17, 2008)

*ER Physicians*

Thank you for all the responses: It just seems like an ER Physician should be separate billing compared to physicians who work in the clinic setting. With all our physicians who work in the office we really have to watch our New Patient rule for coding and this just makes it more difficult. If a patient enters our ER dept and then starts seeing a physician in one of our offices, that patient is established because of that ER Visit. Specialty physicians are the only ones that are easy to check when they see a new patient 
Sheila Sweetland:


----------



## FTessaBartels (Nov 18, 2008)

*No ER specialty?*

Sheila,
If your family practice or pediatricians or internists are coving the ER and then the patient later comes to the clinic to see that same specialty, then yes, it's an established patient.

If your ER physicians are certified in emergency medicine, and then the patient is coming to your clinic to see the family practice or internist or pediatrician, they are a different specialty and would bill as a NEW patient (unless the patient had been seen by that specialty, that practice in the past 3 years).

This happens even with specialists, Sheila. Sometimes a specialty will be called to the ER to see a patient in consultation. When the patient later comes to that specialty clinic, the patient is established. 

It may not seem "fair" but those are the rules. 

F Tessa Bartels, CPC, CPC-E/M


----------

