Cardiology Coding Alert

Although many cardiologists routinely bill encounters in the emergency department (ED) as consultations, in some cases this is inappropriate. National Medicare guidelines state that emergency department codes (99281-99285) should be used, unless these services qualify as admission (inpatient or observation) or critical care services.

In fact, there are at least seven different ways to bill an ED encounter, depending on the status of the patient:

1. Emergency room visit
2. Consultation
3. Admission
4. Admit to observation
5. Critical care
6. Established patient visit
7. New patient visit

These choices may make it difficult to code ED services provided by the cardiologist. To bill appropriately, coders depend on the cardiologists documentation of the encounter. Instead, what they often get is a short note that says, ED consult or Met patient in ED, without other documentation to support a consultation. To avoid claim denials, cardiologists need to provide expanded information of the encounter to their coders.

Consultations in the ED

Possibly the biggest area of confusion when cardiologists bill for ED services is consults. According to the Medicare Carriers Manual (MCM), If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are met.

The three criteria are stated in the MCM, section 15506:

1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by (the ED) physician.
2. A request for a consultation from (the ED physician) and the need for consultation must be documented in the patients medical record.
3. After the consultation, the consulting physician prepares a written report of findings that is provided to the (ED doctor).

In the hospital setting, a separate report is not required. The report can be an entry in the patients common medical records (i.e., progress notes, recommendations for treatment, etc.). Section 15506 states: In an emergency department or inpatient or outpatient setting in which the medical record is shared between the referring physician and consultant, the request for consult may be documented as part of a plan written in the requesting physicians progress note, an order in the medical record or a specific written request for the consultation. In these settings, the written report required for consult may consist of an appropriate entry in the common medical record.

If the criteria listed above are not met and the patient either is discharged from the emergency department or admitted to the hospital by another physician, the cardiologist contacted by the ED physician should bill an ED visit, not a consult. If the consultation criteria arent met, and the cardiologist admits the patient, an initial hospital care code should be billed.

Although many cardiologists believe that because they are on call they are by definition performing a consult and routinely bill visits to the ED as such. This often is incorrect. This error particularly relates to Medicare, which states that consults should not be billed if the intent of the ED physician was a transfer of care. If there was no clear intent to transfer care, even if the cardiologist takes over management of the patients care, the service may still qualify as a consult.

AMA guidelines state that at the point of assumption of care, therapeutics and diagnostics can begin without loss of consult status for that first visit, says Gay Boughton-Barnes, CPC, MPC, CCS-P, a cardiology coding and reimbursement specialist in Tulsa, Okla. After that, she notes, a transfer of care has occurred and no further consults may be billed.

The service can only be considered a consult if the ED physician asks the cardiologist for advice on how to treat the patient. And even then, if the ED physician already has done a workup on the patient, the cardiologist may not be able to bill for a consult.

On the other hand, if a patient has chest pains, pallor, diaphoresis and an abnormal electrocardiogram (ECG), and the ED physician suspects the patient is having a myocardial infarction (MI) but is uncertain, he or she may call in a cardiologist to evaluate the patient and make a recommendation. The cardiologist visits the patient in the ED, looks at the ECG, tries to stabilize the patient and determine if the patient should be admitted. The cardiologist also decides whether the patient should receive a thrombolytic, or an angiogram, and whether the patient is strong enough to undergo a limited (e.g., pharmacologic) stress test.

In this instance, a consult may be billed, Boughton-Barnes says. If, however, the cardiologist just happened to be on call or was doing rounds and therefore ended up reviewing the ECG, no consult can be billed, as there was no formal request for advice.

Note: If the ED physician calls on the cardiologist to perform a predetermined or elective test, or diagnostic procedure, only the procedure or test should be billed, because history and physical already has been performed.

Giving Established Patient Consults

A consult also may not be charged if the cardiologist sends his or her own patient to the ED, and later is asked for advice by the ED physician. If, based on the opinion of the cardiologist, the patient is sent home, both the ED physician and the patients cardiologist should bill the appropriate level of ED service, according to the Medicare Carriers Manual. The cardiologist does not bill for a consultation because he or she is not providing information to the ED physician for use in treating the patient, even though the ED physician asked for the cardiologists opinion.

Even if the patient is sent home, the visit still may qualify as a consult as long as the cardiologist is not treating the patient for the same problem and his or her opinion is requested and then given in writing to the requesting physician, Boughton-Barnes says. In practical terms, she adds, this means that to bill for a consult, the cardiologist needs the discipline to document what occurred and write a follow-up note with recommendations.

Note: If the patients personal physician does not come to the hospital to see the patient, but only advises the emergency department physician by telephone, then the patients personal physician may not bill anything at all.

Second Physician Also Can Bill ED Services

Revised guidelines in section 15507 of the MCM clearly state that non-ED physicians, including cardiologists, should bill such services using ED codes even if the emergency physician who initially saw the patient also bills using the same codes.

Many carriers (local Medicare and private payers), however, do not follow Medicares lead on this issue, and will only pay one ED code per day regardless of the number of physicians who saw the patient. Consequently, coders should contact their carriers to determine the best way to bill in these situations.

In August 1999, Medicare revision no. 1644 changed the guidelines for ED services and instructed physicians to use ED codes even if an emergency room physician also bills for the same service. Some local Medicare carriers, such as First Choice in Florida, clarified their policies to conform to the new wording in the MCM. The MCM guidelines in section 15507 now state:

These codes should be paid regardless of whether the physician is assigned to the emergency department.
Any physician seeing a patient registered in the emergency department may use these codes.
ED codes should be used only if the patient is seen in the emergency department.
ED codes should be paid regardless of whether the services were emergency services, as long as the patient was seen in the ED. A lower-level ED code should be reported for a non-emergency condition.

Before the new policy was announced, the problem was how to bill if a patient came to the ED, saw a specialist and wasnt admitted to the hospital, says Kathy Pride, CPC, CCS-P, a coding and reimbursement specialist at Martin Memorial Hospital in Port St. Lucie, Fla. We never had a clear directive from our local carrier, so we relied mostly on word of mouth, basically, about how to do it. Some consultants said it was OK to charge for a consult; then, when consults came under scrutiny, we were told to use office or other outpatient codes (99201-99215), with the ED as the place of service.

Under the new guidelines, cardiologists who see patients in the ED can bill for any evaluation and management (E/M) services performed there using emergency department E/M codes, unless (i) the patient is admitted by the cardiologist to the hospital or to observation on the same calendar date, in which case initial hospital care or admit to observation codes should be used; (ii) the encounter meets the criteria for a consult or for critical care services; or (iii) the patient is not registered at the ED, even though he or she met the cardiologist there. In such cases, an outpatient visit code should be reported, with 23 (for ED) listed as the place of service.

Note: This likely will be subject to a site of service differential, whereby the carrier lowers the fee to reflect the fact that the physicians office costs arent taken into account because the service was provided elsewhere.

Until MCM guidelines were revised, most private payers and many local Medicare carriers accepted only one ED claim per patient per day. So if an ED physician saw a patient and then asked a cardiologist to take over care of the patient, the cardiologist had two options: If the patient was admitted, an initial hospital visit code was billed; if the patient remained in the ED, the cardiologist would bill the encounter as a new or established patient outpatient visit.

A new or established patient outpatient code also may still be required by some payers, including some local Medicare carriers, that still look askance at concurrent emergency department billing by an ED physician and a cardiologist or other specialist. Billing such carriers with an ED code often will result in the cardiologists claim being denied. Although appealing such denials may be successful, doing so again and again can be time-consuming. So coding experts recommend getting the carriers policy on MCM section 15507 (preferably in writing) before billing ED E/M codes.

If the carrier will not recognize two ED codes on the same day for the same patient, an outpatient code should be used with the ED listed as the place of service on the HCFA 1500 claim form.

Note: If local Medicare carriers deny the cardiologists ED E/M claim, the Medicare Carriers Manual, section 15507, should accompany any appeal. If these denials become routine, a form letter identifying the revision should be developed.

Coding Critical Care in the ED

Patients may require critical care, defined by CPT as medical care of a patient with a critical illness or injury that acutely impairs one or more vital organ systems, such that the patients survival is jeopardized, when he or she arrives at the emergency department.

The codes for critical care services 99291 and 99292 are time-based and require a minimum of 30 minutes for billing; they also may be billed by only one physician per patient per time period. These restrictions mean that the care the cardiologist provides at different times may be similar, but depending on the circumstances, either a critical care code or a level-five emergency department E/M code may be billed.

Note: Because ED service codes are not time-based, they cannot be prolonged. As such, prolonged services codes cannot be claimed in addition to ED codes, whereas they can be claimed together with critical care codes if the times are documented and other requirements are met.

Billing Same-day Services

ED codes should not be reported on the same day critical care services are billed. According to section 15508 (rev. 1644) of the Medicare Carriers Manual, If critical care is required upon the patients presentation to the emergency department, only critical care codes 99291-99292 may be reported. Emergency department codes will not be paid for the same day.

Regardless of the patients condition or the service provided, unless the cardiologist spends at least 30 minutes with the patient and the documentation supports the criteria for critical care, this service cannot be billed, and (presumably) a level-five emergency services E/M code should be used instead.

The clinical criteria for using a level-five emergency code are not that different from those used for critical care. According to the CPT manual, for a level-five ED visit, usually, the presenting problem(s) are of high severity and pose an immediate threat to life or physiologic function.

If two physicians work on a critical patient and both satisfy the critical care criteria, only one may bill using a critical care code per time period. The physician who worked on the most difficult problem would bill for critical care; the other doctor would use a level-five emergency code.

Note: CPT code 92950 (cardiopulmonary resuscitation [e.g., in cardiac arrest]) may also be appropriate in some situations.

Choosing the Right Admit or Observation Code

If the cardiologist sees the patient in the ED and then admits the patient to the hospital on the same calendar date, only an admission code (99221-99223) can be billed, according to the MCM. All E/M services provided by the cardiologist are considered part of the initial hospital care when performed on the same date as the admission.
If the cardiologist sees the patient in the ED on day one and admits the patient on day two (defined as beginning at midnight), even if fewer than 24 hours has elapsed, an ED visit may be billed for day one and an admission billed for day two, according to the MCM.

The same rules apply for admitting a patient to observation; however, the place of service must be specified and must agree with the hospitals own documentation regarding the patient.

If the patient is having an MI, is admitted and taken directly to the cath lab, both the cardiac catheterization and the admission should be billed; however, modifier -25 should be appended to the appropriate admission code (which could be an admit to hospital, observation, or same-day admission or observation and discharge code) to indicate the examination was a significant, separately identifiable service; otherwise, the admit will be bundled into the appropriate catheterization code, Boughton-Barnes says.

Note: For more information on observation E/M services, see Cardiology Coding Alert, Four Simple Guidelines to Help Minimize Observation Denials, Vol. 2, No. 11, November 1999.

For example, a patient is admitted to observation for 24 hours for evaluation of chest pain. Even though the patient is seen in the ED, the cardiologist should bill an admit to observation code (99218-99220), as long as the place of service (section 24b on the HCFA 1500 claim form) was listed with a 22 to designate outpatient/hospital status. The hospitals own claim for the encounter, however, must also indicate that the patient was placed in observation, otherwise the claim may be denied.

Some coders and physicians may confuse observation and inpatient status, particularly if the patient first arrives in the ED, which is its own place of service (23). In
addition, many cardiologists are unaware that there are newer observation codes (99234-99236) that should be used when a patient is admitted (either to hospital or observation) and then discharged on the same day.

Cardiologists also should break out the calendar days they saw the patient on. If a patient is seen on the ED floor in the morning and then admitted in the evening, everything that transpired on that calendar day is included in the higher level of service (i.e., the admission).

Finally, if the cardiologist performed a level-five ED service and admitted the patient the next day with minimal history and physical (H&P), only a level-one (99221) initial hospital care should be used for the admission, according to the MCM.

ED Visit Codes Emergency department (ED) services are coded 99281-99285 (emergency department visit for the evaluation and management of a patient), depending on the level of history, examination and medical decision-making, as follows: 99281 problem-focused history and examination, and straightforward medical decision-making 99282 expanded problem-focused history and examination, and medical decision-making of low complexity 99283 expanded problem-focused history and examination, and medical decision-making of moderate complexity 99284 detailed history and examination, and medical decision-making of moderate complexity 99285 comprehensive history and examination, and medical decision-making of high complexity