ED Coding and Reimbursement Alert

To correctly code for a patient who presents in the emergency department (ED), including attempted treatments that were unsuccessful, coders must determine what, if any, procedures can be reported in addition to the overall service.

We provided the following documentation example to two expert coders and asked their opinions of the correct way to code the visit. In this case Dr. B is the emergency room physician (providing the documentation) and Dr. K is the surgeon.

Documentation of Examination and Treatment

History: This is a 79-year-old white male with the chief complaint of abdomen pain. Patient has been having abdominal pain for the past three to four days and in the past 24 hours, has had a lot of vomiting and some diarrhea. Discomfort seems worse and unrelenting. Hard to take a deep breath. Denies fevers, discomfort, congestion, trauma or otherwise contributing to his symptomatology. His medications include Isosorbide, Coumadin, K-Dur, Lasix, Verapamil, Digoxin and Lisinopril.

No known allergies.

Past Medical History: Hypotension, congestive heart failure, atrial fibrillation, shoulder pain, arthralgia and degenerative joint disease.

Review of Systems: Negative. No other contributory surgical history.

Physical Examination: Vitals were afebrile and pulse was irregular at 84-100. Respirations were 22. Blood pressure was 120/70. On examination, the patient is awake, alert, and appears uncomfortable, a bit diaphoretic and pale. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Anicteric and non-injected sclera and conjunctiva. No oropharyngeal mucosal changes. Lungs are clear. Heart is regular, maybe S-1 systolic murmur. No gallops. Abdomen is protuberant, hypertympanitic bowel sounds, diffuse tenderness, particularly the left side. He has an umbilical hernia that really does not appear to have entrapment, but he has an incarcerated left inguinal hernia which cannot be reduced at this time. His back is nontender, and the extremities are without clubbing or edema. Uncircumcised genitalia. Rectal examination is unremarkable.

Emergency Department Evaluation: Included abdominal series that showed partial bowel obstruction. Serum WBC count of 15, with left shift 15.6, hemoglobin 12.4, amylase, pro-time 30 with an INR of 2.7. Electrolytes were normal other than BUN of 24, creatinine of 1.5 and glucose of 287.

Diagnosis: Incarcerated left hernia with bowel obstruction.

ED Management and Disposition: The initial attempt at reduction was unsuccessful and the patient was subsequently placed in Trendelenberg under conscious sedation with morphine and Versed. After multiple attempts of incarceration, the bowel was reduced into the peritoneal cavity again, leaving a large vacant left inguinal hernia. Subsequently, he was discussed with Dr. K who evaluated him here in the emergency department, and then he was admitted to the step-down unit for further intervention and evaluation. He was treated with multiple meds here in the department as outlined on his chart. Stable upon transfer to the floor in guarded condition.

The Experts Opinions

Sharon Garfield, CPC, compliance specialist for physician billing in the Department of Emergency Medicine at Mercy Health System in Conshohocken, Pa., advises that hernia reductions fall under the evaluation and management (E/M) code because CPT doesnt actually have a code for hernia reductions.

In this situation, Garfield recommends reporting only the appropriate E/M code (99281-99285, emergency department visit for the evaluation and management of a patient, requiring various levels of history, examination and decision making) and a conscious sedation code (99141-99142) if the physician provided separate documentation of the required monitoring for conscious sedation.

According to CPT, conscious sedation includes performance and documentation of pre- and post-sedation evaluations of the patient, administration of the sedation and/or analgesic agent(s), and monitoring of cardiorespiratory function (i.e., pulse oximetry, cardiorespiratory monitor and blood pressure). The use of these codes requires the presence of an independent trained observer to assist the physician in monitoring the patients level of consciousness and psychological status.

In this record, there is no mention of the pulse oximetry and cardiac monitoring that is required by CPT for the reporting of conscious sedation, she says. If they do not provide more detailed information about the performance of conscious sedation, then I would not report that code either.

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., says, There is no service billable by the physician in this case except the appropriate level ED visit (99281-99285). The conscious sedation is not billable since Medicare considers (at 79 years of age, the patient would be a Medicare patient) this to be a facility service and the supervision of the service to be bundled into other services provided at the same session (in this case, the E/M service). Callaway-Stradley explains that most commercial carriers follow Medicares lead in considering conscious sedation a facility fee. If there were a carrier that allowed billing of conscious sedation by the physician, a reference to any additional records documenting that service would be a recommended addition to the physicians note, she adds.