ED Coding and Reimbursement Alert

"CPT has assigned codes for all of these procedures, so it is understandable why coders believe they represent reportable services," Thomas says. "But when they are performed by nursing staff, not doctors, they can't be billed."

You can, however, bill incident-to codes when the physician performs the services, Thomas adds. A patient involved in a motor vehicle accident (MVA) may have an injury to the neck that interferes with NG tube placement. In this case, it's appropriate for the physician to drop the tube. Patients who are vomiting may also require a physician's experience to insert the tube. And the physician may step in to complete the procedure if a nurse repeatedly tries to place the tube but fails.

"The key is medical necessity," Thomas says. "If there is a clear reason why the physician had to provide the service, and that reason is documented in the medical record, coders can report the procedure."

You should also be aware that in CPT 2001 the AMA added code 43752 (Naso- or oro-gastric tube placement, necessitating physician's skill), which is now more appropriate for these cases.

These exceptions don't include convenience factors. For instance, if a physician starts an infusion because no nurses are available, the service "cannot be reported even though the physician performed the service because it was not medically necessary to do so," Thomas says.

Coding for splinting and strapping services is not so clear-cut. Some coding experts argue that the physician must apply the stabilizing device in order for you to report the service. Others maintain that these codes may be billed if the nurse applies the splint but the physician subsequently documents its effectiveness.

While CPT supports the latter argument, local Medicare carriers have devised individual policies. You should ask your medical director if you may code splinting and strapping performed by personnel other than the physician. If your local carrier allows billing for splints applied by nurses, it is important to document in the chart that the physician ordered the splint and then checked it before the patient left the hospital.

Coding professionals urge caution in this area. Most suggest a conservative approach for governmental payers unless the local medical review policy (LMRP) advises otherwise. They note that, because Medicare has specifically removed the application of incident-to guidelines from the ED, the physician must be personally involved in the splint's or strap's placement.

For nongovernmental payers, a more liberal approach might be appropriate. "If the physician checks the positioning of the splint or strap, makes sure it will be effective and verifies it doesn't interfere with circulation, the procedure should be coded and billed," Thomas says.