ED Coding and Reimbursement Alert

Emergency department (ED) physicians occupy a unique position in the healthcare field one that causes big challenges for coders. Often, doctors in an emergency setting collaborate with their medical colleagues to provide the best care for patients. They may work with cardiologists when an elderly patient presents with severe heart dysrhythmias, with members of a specialized trauma team following a grievous automobile accident, and with radiologists to determine the cause of a young patient's headache. These scenarios raise a dilemma for coders.

"Concurrency-of-care issues within emergency medicine have been debated over the course of many years," says Kenneth DeHart, MD, FACEP, president of Carolina Health Specialists in Myrtle Beach, S.C., and past member of the CPT Editorial Panel. "CPT makes it very clear that physicians may submit any CPT code for which they provide service. However, many payers are equally clear that they won't reimburse two physicians for the same service provided to the same patient on the same day."
 
When deciding which physician to pay, he adds, payers use rules that may be capricious and arbitrary. "In some cases, insurers try to determine who did the most work and award the benefit in that manner. At other times they simply pay whichever physician's bill is received in their offices first."
 
In addition to impacting the bottom line, these issues also strain collegial relations within the facility, he notes. Each physician who cares for the patient feels entitled to reimbursement, and resentments flare when payments end up in another practice's coffers.

To take the guesswork and politics out of coding and reimbursement, DeHart recommends three strategies:

 

Document thoroughly and submit supportive paperwork. When claims are submitted with documentation that clearly substantiates the services, insurers are more likely to respond with full payment. "A lot of coders balk at the idea of having to send paperwork in to insurance companies," says Carol Dodd, RHIT, senior coding consultant in the department of coding and information services with Medquist in Gibbsboro, N.J. "But we must remember that the coding process was not developed to exclude physicians from getting what they earn. When coders take a little extra time to dot their I's and cross their T's, they can show the payers the documentation that demonstrates that a specific level of service was truly provided. Then the practice will get paid what it deserves." 

 

Develop specific policies with other departments that address concurrent care issues before they arise. Communication is key, DeHart says. "Often, this has to be decided within the local political environment. The hospital must establish policies that treat contributing physicians fairly." Then coding experts can work cooperatively to determine the most appropriate method to use when billing a specific case.

 

Scrutinize the services provided and ensure that payment expectations are realistic and ethical. "I urge all ED physicians and coders to take a hard look in the mirror on occasion," DeHart says. "We all need to ask if we truly provided a significant and substantial portion of service when two physicians are involved. If the other physician did the majority of the work, he or she should be coding the service."

DeHart says that concurrent care issues crop up most frequently when services overlap in three specific areas:

 1. E/M services. "Problems may arise, for instance, when more than one physician is involved in critical care," DeHart says. A trauma patient may arrive in the ED, and the physician on duty tends to the patient until a trauma surgeon is called and arrives to take over.

Similarly, a pediatric patient may arrest in the ED, and resuscitation is performed by the ED physician. Later, a pediatric specialist assumes care for the young patient. Because critical care codes (99291, Critical care, evaluation and management of the critically ill or injured patient; first 30-74 minutes, and +99292, each additional 30 minutes [list separately in addition to code for primary service]) are reported in 30-minute increments, it is conceivable that two physicians may submit claims. Some payers, including many state Medicaid programs, will honor only one of these claims, however.
 
"Ultimately, ED physicians must document when and where their care was rendered," DeHart says. Dodd agrees, adding that chart notes should include not only the total time spent with the critical care patient but the times when face-to-face care began and when each session ended. In addition, a description of each specific service provided should be clearly outlined.
 
There are occasions when two physicians report ED codes (99281-99285). "For instance, an ED physician in an outlying area may stabilize a patient and then transport the individual to a larger center," DeHart says. "There, care is given by another member of the same group reporting with the same tax ID number. In this case, only one may report the service. In another case, an ED physician may treat a patient with renal colic (788.0, Symptoms involving urinary system; renal colic). Later, the urologist comes in and, when the patient is free from pain, discharges him. Because the two physicians are of a different specialty and report under different tax ID numbers, both claims might be paid."
 
He adds that, to date, CMS has allowed more than one E/M claim to be paid when reported by different specialties. However, as budget constraints continue to squeeze the Medicare program, this issue may resurface.

 2. Procedural services. "A classic example is found in fracture care," he says. "Perhaps the ED physician treats a female patient with a distal radial fracture, performing a closed reduction with no manipulation (25600, Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture of ulnar styloid; without manipulation). The physician invokes the global fracture care code because she feels that she provided a significant portion of the global care. However, the ED physician would use modifier -54 (Surgical care only) on the global code (25600-54). Then the orthopedic surgeon will code the fracture code appending modifier -55 (Postoperative management only) to indicate the follow-up nature of his involvement (25600-55). The use of these modifiers splits the global fee so each physician will get paid a percentage of the global fee based on his or her involvement. By using the global code in the first instance, the ED physician prevents the orthopedic surgeon from getting any payment, which is inappropriate billing because the ED physician will not be assuming the follow-up care.
 
DeHart notes that, in some cases, payers may require that the orthopedist providing follow-up use an office-based E/M code from the 9920x series (Office or other outpatient visit; new patient) instead of 25600-55.
 
"These are the instances," he says, "when ED physicians and coders must be certain that they truly provided a substantial percentage of the service in order to ethically expect reimbursement. These cases have the potential for terrific political spillover. We need to look in the mirror to be certain we can justify the payment we are asking for and are diverting from the orthopedist."
 
3. Interpretive services. "Interpretive services are generally the focal point of controversy for concurrent care," DeHart says. "CMS has been very clear that it will pay only one provider for interpretive services such as reading x-rays (e.g., 71020, Radiologic examination, chest, two views, frontal and lateral) or EKGs (e.g., 93010, Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only)," he notes. "Most other payers follow suit."
 
Dodd adds that CMS is equally clear that ED physicians who provide these services may be paid: "ED physicians must realize they will be paid to interpret an x-ray if they make out a separate report just as the radiologist would, for example. This report has to be separate from any chart notes that would be factored in as part of the medical decision-making component of an E/M service."
 
Nonetheless, if both the radiologist and ED doctor interpret the x-ray, only one will be paid. "If both bill," DeHart says, "most payers will reimburse the interpretation that was rendered with the disposition of the patient." The CMS literature uses the word "contemporaneous" to describe this concept and uses the example of interpretation completed while the patient is in the ED, as opposed to hours or days after he or she has gone home. "In other words," he says, "if an x-ray is ordered at 3 a.m. and the hospital has no radiologist on duty, the ED physician would be paid for the interpretation even if the radiologist later reviewed the x-ray and wrote another report. Similarly, if the ED physician ordered an EKG on a critical patient, and treatment decisions were made based on the interpretation before the cardiologist arrived, the ED physician would report the service."
 
Dodd notes that when the ED physician cannot report an interpretive service, review of the image or test results should nonetheless be documented in the medical decision-making portion of the ED service. "While the coder may not report the interpretation service, the appropriate ED code can still be assigned. The review will increase the data test complexity and may add to the level of service that may be billed." She cautions, however, that interpretation and review of tests, scans or images may not be billed as a separate service and factored into the ED code.