ED Coding and Reimbursement Alert

Because Medicare's "incident-to" rules don't apply in a hospital setting, coders who aren't ED experts could be making some costly errors.

It's not unusual for patients in the ED to undergo nasogastric (NG) tube insertion, urinary catheterization, and other routine procedures. However, nursing staff typically perform these services, and reimbursement is included in the facility-side payment. Therefore, an established pattern of coding the professional fees may constitute fraud. Five types of procedures are particularly problematic, says Todd Thomas, CCP, CCS-P, president of Thomas and Associates in Oklahoma City: 91105 Gastric intubation, and aspiration or lavage for treatment (e.g., for ingested poisons) 53670* Catheterization, urethra; simple 90780-90781 Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour, and each additional hour, up to eight (8) hours (list separately in addition to code for primary procedure) 90782-90788 Therapeutic, prophylactic or diagnostic injections 29105-29280 Application of splints and strapping. "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." Medical Necessity Allows for Exceptions 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. Splinting and Strapping Policies Differ 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 [...]