ED Coding and Reimbursement Alert

Receiving reimbursement for nonemergent cases can be difficult because although the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations state that the hospital cannot refuse a medical screening exam (see box on page 60), the carrier bases payment strictly on the level of medical decision-making or on the diagnosis submitted. A carrier might reduce or deny payment for nonemergency services performed in the ED or pay the hospital only -- and not the physician -- if it determines the presenting problem, as described by the submitted diagnosis, was not an emergency.
 
Medicare states that emergency codes must be paid regardless of whether the presenting problems are "real" emergencies. Codes 99281-99285 (emergency department visit for the evaluation and management of a patient) cover nonemergent care in the ED as long as it is:
 
1. an organized, hospital-based facility
2. open 24 hours
3. designed to provide services to patients who present for immediate medical attention for unscheduled episodic events.

 
"When billing both emergent or nonemergent visits, do not confuse a clinical, medical opinion with a billing decision," says John Turner, MD, PhD, medical director of documentation and coding compliance for Team Health in Knoxville, Tenn. "The billing department cannot code based on emergent or nonemergent status, only according to what the medical record will support. A specific diagnosis or symptom cannot always dictate whether a patient's problem represented a true emergency condition. This is why CPT has not developed codes for emergent or nonemergent care." This is a problem because the service is not initiated by the provider or the insurer. Patients decide whether they're having an emergency, and that is why they come to the ED. EMTALA requires the hospital to see these patients, and it is only after the exam that the classification of emergent or nonemergent can be made.
 
For example, at 3 a.m. Sunday a worried mother comes to the ED with her baby, who has a high fever and is crying continuously. The emergency physician examines the infant and diagnoses otitis media (382.9), a minor inflammation of the middle ear. Although the diagnosis indicates that this was not an emergency, the mother was convinced that her child needed emergency care. Carriers, including Medicare, must pay the 99281-99285 ED E/M codes because the facility met its three nonemergent criteria.

 
EMTALA mandates that every patient receive a medical screening, which is used to determine if the patient's condition qualifies as an emergency. If it does not, the physician does not have to provide care in the ED. But, there is little difference between the work required to determine the existence of an emergency medical condition and performing a regular E/M visit. To ensure reimbursement, it is better to code based solely on the value of the work performed rather than on the results of the medical screening.
 
The best approach for coding and billing an ED visit is to remove value judgments from the equation, Turner says. Tracie Christian, CPC, an emergency coding expert with Pro Code, a large ED management firm in Dallas, stresses that patient presentations (even if those are not emergent) are coded according to the CPT guidelines and assigned the E/M level supported by the physician's documentation.
 
"Take a chart at face value and code it according to the work and services provided," Turner says. "Remember that the diagnosis and disposition of a patient should not necessarily determine the E/M level. The most important element of a chart is the medical decision-making (MDM) -- and that should be the initial focus of coding. Decide the value of the chart through the MDM, and then see if the history and exam support this value."

Code Signs and Symptoms
 
 
Coding signs and symptoms first informs the payer why patients present to the ED before seeing their primary care physician (PCP) and might also provide support for the prudent-layman's rationale for reimbursement of the visit. Medicare and many insurance payers follow this federal law, which says that the patient determines the need for the visit. Basically, if the patient feels that his or her condition necessitates an emergency visit, it's an emergency.
 
Note: For more information about the prudent-layman standard and the history and background for coding signs and symptoms of the presenting problem, see the July 2000 Ed Coding Alert.
 
"The difference between how we might code one of the 'nonemergent' presentations versus the truly 'emergent' presentations is if the ED physician's MDM indicates that the presenting problem (signs and symptoms) qualifies as a medical necessity even if the final diagnosis proves otherwise," Christian says.
 
For example, a mother presents with her 7-month-old because the baby has a fever of 102.5 and has been vomiting all evening. The final diagnosis is viral syndrome, 079.99. In this case, code the presenting problems first (the fever [780.6] and vomiting [787.03]) and the final diagnosis last. The presenting problems of high fever and continual vomiting could be considered an emergent problem, although the viral syndrome might not. On the other hand, when patients present with truly emergent illnesses (e.g., CVAs, myocardial infarction, appendicitis), it is not necessary to justify the visit by coding symptoms first. In these cases, code the final diagnosis as the presenting problem.
 
Therefore, coding signs and symptoms first does not necessarily support the E/M level, except in relation to the MDM -- but it might allow the payer to distinguish an emergent presentation from a nonemergent diagnosis. Claims for both emergent and nonemergent services should be reimbursed if the physician documentation supports the E/M level assigned, including all elements of the history, examination and MDM. Sometimes ED physicians or staff perform medical-screening exams and follow-ups, but these should also be supported by the documentation. If denials occur for nonemergent presentations, the claim should be reviewed for appropriate coding and resubmitted.

 
"We have seen an increase in follow-up care in our EDs, mostly because a patient's PCP is on vacation or is simply too booked," Christian says. "We especially see more children, and more accident claims in general, during the summer months -- everything from insect stings to poison ivy to imbedded fish hooks." Although not all follow-up cases are nonemergent, some are.   Christian says ED physicians generally assign a lower-level E/M for patients who present to the ED for follow-up such as cast or suture removal after initially being treated by another physician or facility. To ensure against "double billing," ED physicians rarely use procedure codes, but the need can arise.
 
For example, a patient received fracture care and casting from his orthopedist, and the orthopedist bills for his or her services. If the patient presents to the ED instead of returning to the orthopedist for cast removal, the ED physician could submit a code for removing the cast. Although, according to CPT, "removal or repair codes (29700-29750) should be employed only for casts applied by another physician," if the orthopedist billed the fracture-care services as a package and the ED physician bills for cast removal, the removal would be billed twice. In this case, the ED physician's claim might be reimbursed, but the orthopedist's bill will probably be denied.
 
But if the patient presents to the ED because of a new injury occurring after a procedure, the ED physician could bill the procedure code. For example, the PCP performed suture repair, but the patient reinjured the site and presented to the ED to have the same wound resutured. In this case, the CPT codes for suture repair submitted by the ED and the PCP might be identical  but the physician's provider numbers and the locations/facilities would be different. Medicare would also recognize the difference in specialty indicators. And the diagnosis code used by the ED physician would reflect the additional complication. If these claims present a problem for the payer, the two records would likely be requested for review. Both physicians' documentation should support the services provided and therefore support reimbursement for both claims.

After-Hours Codes
 
 
"Patients present to the ED 24/7 (after-hours, Sundays and holidays, too), and about half are nonemergent," Christian says. "Many might not have a PCP and must go to the ED for an illness or injury." Also, the pressures of the current managed-care market might create limited access to physicians, making it necessary for their patients to visit the ED for new problems and routine care.
 
Certain circumstances of time, date or day of week can influence a patient's visit to the ED. Christian says visits to the ED after private-practice office hours with nonemergent illnesses are reported using the appropriate ED E/M level along with the "after-hours" or "Sunday/holiday" codes 99052 (services requested between 10 p.m. and 8 a.m. in addition to basic service) and 99054 (services requested on Sundays and holidays in addition to basic service). The after-hours codes inform the payer that the patient presented because a PCP was unavailable and further support the case for reimbursement, particularly by private payers.
 
Be aware that the after-hours codes have no assigned relative value units. "Some physician groups/facilities choose not to assign them because some payers will not reimburse them," Christian says.