ED Coding and Reimbursement Alert

You can separately report transport services if the code conditions are met.

Patients in the emergency department frequently need transfers to or from another venue to receive the care they need. The emergency physician is typically involved in these transfers, but not all of that work is separately reportable from the E/M service. Read on to find out what can and cannot be reported separately.

This has been an area of some confusion over the years, says Michael A. Granovsky, MD, FACEP, CPC, President of Logix Health, an ED coding and billing company in Bedford, MA. However, an in-depth discussion of ambulance transport codes in the May 2013 CPT Assistant^® may shed some light.

It is not at all uncommon for a physician in the ED to provide medical direction via radio to EMS personnel in the field. A code exists for this service, 99288 (Physician or other qualified health care professional direction of emergency medical systems [EMS] emergency care, advanced life support). These must be transports of an emergency nature requiring advanced life support rather than a routine transfer, or even transporting a patient from a nursing home to the emergency department for a routine checkup, explains Granovsky. 

CPT^® says that the code is intended to cover the direction of necessary medical procedures including but not limited to: telemetry of cardiac rhythm, cardiac or pulmonary resuscitation, endotracheal or esophageal obturator airway intubation, administration of IV fluids and/or administration of intramuscular, intratracheal or subcutaneous drugs and electrical cardioversion.

Drawback: Code 99288 has no RVUs assigned and is frequently not covered by payers. They consider it to be part of the preservice work of the E/M service when the patient does arrive in the ED and the physician takes over the patient’s care. In the less likely event that the radio direction is for a patient that does not come to the ED where the physician is working, there is no face-to-face encounter so that service has historically not been reportable either, says Granovsky.

Heed Rule Differences for Peds Patients

Changes in the regionalization of care have caused an increase in the number of transfers from one facility to another, especially for pediatric and neonatal patients.

There are specific codes in the 2013 CPT^® book for transporting critically ill or injured kids under two years of age requiring the physical attendance and direct face-to-face care by a physician during the interfacility transport. These are 99466 (Critical care face-to-face services, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; first 30-74 minutes of hands-on care during transport) and 99467 (Each additional 30 minutes [List separately in addition to code for primary service]).

Key: Unlike code 99288, these require face-to-face care, which starts when the physician assumes primary responsibility of the pediatric patient at the referring facility, and ends when the receiving facility accepts responsibility for the pediatric patient‘s care. You can only report the time the physician spends in direct face-to-face contact with the patient during the transport, so any time spent traveling to the transferring facility to collect the patient cannot be counted towards the minimum time threshold.

Pediatric patient transport services involving less than 30 minutes of face-to-face physician care should not be reported and any procedure or service performed by other members of the transporting team may not be reported by the supervising physician, says Granovsky.

No Face-To-Face Time For Directing A Pediatric Transfer? There’s A Code For That Too

If there is not face-to-face care for the critical  pediatric transfer patient, but the physician is directing emergency care through outside voice communication to transporting staff personnel, those service can be reported using new codes for 2013, 99485 (Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes two-way communication with transport team before transport, at the referring facility and during the transport, including data interpretation and report; first 30 minutes) and 99486 (…each additional 30 minutes [List separately in addition to code for primary procedure]).

Report supervision: Understand that codes 99485, 99486 are used to report the control physician’s, (meaning the one directing the transport service), non-face-to-face supervision of interfacility pediatric critical care transport, which includes all two-way communication between the control physician and the specialized transport team prior to transport, at the referring facility and during transport of the patient back to the receiving facility.

Critical: These codes do not include pre-transport communication between the control physician and the referring facility before or following patient transport. The control physician provides treatment advice to a specialized transport team who has direct contact and is delivering the hands-on patient care. The control physician does not report any procedures provided by the specialized transport team. The control physician’s non-face-to-face time begins with the first contact by the control physician with the specialized transport team and ends when the patient’s care is handed over to the receiving facility team, Granovsky explains.

Because 99485 is a timed code, the established thresholds must be met. Code 99485 is used to report the first 16-45 minutes of direction on a given date and should only be used once, even if time spent by the physician is discontinuous. Services of 15 minutes or less or any time when another physician is reporting the 99466 or 99467 codes for the same patient cannot be reported, says Granovsky.

Watch For Bundled Services With These Transport Codes

According to CPT^®, emergency department services (99281-99285) or critical care (99291, 99292)by the control physician can only be reported after the pediatric transport patient has been admitted to the emergency department, or the critical care unit of the receiving facility.If critical care services are reported in the referring facility prior to transfer to the receiving hospital, use the critical care codes (99291, 99292).

Although it isnot specifically mentioned in the print version of the 2013 CPT^® Book, the online product reminds us that like with code 99291, certain services are included when performed during the pediatric patient transport by the physician providing critical care and may not be reported separately. These include:

·         routine monitoring evaluations (e.g., heart rate, respiratory rate, blood pressure, and pulse oximetry)

·         the interpretation of cardiac output measurements (93562)

·         chest X-rays (71010, 71015, 71020)

·         pulse oximetry (94760, 94761, 94762)

·         blood gases and information data stored in computers (e.g., ECGs, blood pressures, hematologic data) ( 99090)

·         gastric intubation (43752, 43753)

·         temporary transcutaneous pacing (92953)

·         ventilator management (94002, 94003, 94660, 94662) and

·         vascular access procedures (36000, 36400, 36405, 36406, 36415, 36591, 36600).

Any services performed which are not listed above should be reported separately. However, services provided by the specialized transport team are not reported by the control physician, warns Granovsky.