ED Coding and Reimbursement Alert

Get familiar with what codes to report when a patient dies en route

When a patient presents to the ED and the physician declares him dead, coders often struggle to decide whether they should report the physician's work - and how. Our experts tell you what work counts when this scenario unfolds in your ED.

Here's the situation: The local EMS contacts the ED for CPR direction, and the ED physician directs them regarding medication and defibrillation. When the patient arrives in the ED, the doctor examines him and decides to discontinue CPR and pronounce him dead. You billed 92950 (Cardiopulmonary resuscitation) and 99288 (Physician direction of emergency medical systems [EMS] emergency care, advanced life support) to your local Medicare carrier, and it rejected the claim as "not necessary." Why?

Report In-Person Encounters

Medicare may feel that it should not pay the claim because the doctor needs to be face-to-face with the patient to bill for performing cardiopulmonary resuscitation (CPR), and that wasn't the case in this scenario. The physician can bill for running a code in the emergency department, even if he isn't personally doing the compressions, as long as he is at the bedside. However, if EMS performed the physical services in the field - and the physician's involvement is by EMS direction (99288) - you can't bill it as CPR. In this scenario, there is no indication that CPR was continued at the hospital by or under the direction of the emergency physician.

Also, remember that 99288 has status code "B" in the Medicare system, which means the payer recognizes the code but has included the aggregate work (relative value units [RVUs]) for it in the assignment of the RVU for the E/M service the physician provides. So you could report both 99288 and the E/M code, but you will only receive payment for the E/M code.

Use Your Judgment About Work Performed

Because there is work associated with calling the code and pronouncing the patient, you might consider rolling the work of directing the code by radio and the other EMS direction services into a low-level E/M code. Alternatively, some groups may choose not to bill at all in this situation - especially if the physician didn't really deliver any care when the patient arrived in the ED, and the patient was DOA (dead on arrival).

Don't Bill for DOA Patients

If a patient arrives at the emergency department already dead, you're much less likely to report any codes. Frequently, the patient will go directly to the coroner after being declared dead, says Susie Elmore, coding specialist at Clark-Holder Clinic in LaGrange, Ga.

Possible exception: In many cases, the ED physician will perform a detailed examination of a DOA patient to make sure there is no outside trauma, says Pam Fazek, director of coding with Health Care Business Resources, an emergency physician billing company in Bala Cynwyd, Pa. The physician may also take a history from a family member. But most hospitals will ask the physician to "hold off" on billing for those services.