ED Coding and Reimbursement Alert

In addition to choosing the codes to correctly report emergency department (ED) services and procedures, emergency medicine coders also must be alert for violations of federal billing regulations and federal law regarding provision of emergency medical treatment. Sometimes, a dispute over correct coding actually indicates a more serious problem with ED policies and procedures.

A recent question from an ED Coding Alert subscriber illustrates the problem:

We had a patient with an infected pre-patellar bursa come to the emergency room (ER) per doctors orders for a dressing change that included repacking the wound, writes an emergency physician group practice manager and director of emergency services for a hospital in the Midwest. This occurred on a weekend. The ER charges included the supplies used and a charge for the treatment room. The [hospital] coding department states they cannot code as a treatment, they are asking the ER to use an evaluation and management (E/M) code instead. The patient was not seen by a physician on either of two visits. How do we code?,/I>

This question is properly answered in two parts, advises Sharon Timms, RN, quality management, compliance manager for Lynx Medical Systems, an emergency medical billing and consulting firm in Portland, Ore.

Billing E/M Services

First, you should not report an evaluation and management (E/M) code if the ED physician has not seen the patient, Timms explains. To code the emergency service E/M codes 99281-99285, the Health Care Financing Administration (HCFA) documentation requirements must be met for the three key documentation components including history, physical exam and medical decision making, she adds. If the physician does not see the patient, it would be impossible to meet the documentation requirements. Therefore, a professional code for the physician cannot be charged. A facility charge may be applied for resources utilized by the hospital.

However, the practice of having a patient come into the ED, receive treatment, but never see the ED physician or receive a medical screening examination (MSE) is a clear violation of the federal law known as EMTALA (the Emergency Medical Treatment and Active Labor Act).

Passed in 1995, this law requires that all patients presenting to the ED for treatment receive an MSE that is sufficient to rule out the presence of an emergency medical condition. The law also stipulates that the exam must be provided regardless of the patients ability to pay.

Each patient who comes to the ED for treatment must receive a screening examination by a member of the clinical staff designated to perform screening examinations by hospital policy, says Robert Bitterman, MD, JD, FACEP, director of risk management and managed care in the emergency department at Carolinas Medical Center in Charlotte, N.C. Bitterman is also the chair of the managed care section of the Dallas-based American College of Emergency Physicians (ACEP).

Most hospitals have assigned that role to the ED physicianbecause the MSE must either discover a serious illness or reliably rule out the presence of onebut some medical centers have protocols allowing nurses to perform the examination using physician-designed procedures.

The most important thing to remember is that the MSE must be given to each patient regardless of the circumstances of their presence in the ED.

One of the most common errors is for physicians in rural areas to send a patient to the ED and phone in orders for treatment, advises Bitterman. The patient receives the treatment and leaves the department. This procedure violates EMTALA because the patient did not receive the same MSE that another patient presenting with a similar complaint would have received.

It is irrelevant if the patients private physician examined the patient in the office only moments before sending the patient to the ED, he says.

ACEP is now working with the Health Care Financing Administration, the agency charged with enforcing EMTALA, on guidelines that would permit exceptions to the rule for patients who are sent in by the private physician, he continues. But, now, the rule is clear and applies to all patients.

In effect, an E/M code should be used to report the care provided to this patient because the physician should see the patient. If not, and the practice of treating patients without the physicians presence continues, the physician group and the hospital face fines by the federal government and loss of Medicare participation.