ED Coding and Reimbursement Alert

Your first step will involve differentiating between the reasons for the first and second visits.

It happens in every ED from time to time — a patient will come in with a complaint, leave after seeing the physician, and then return later the same day for a second ED visit. Coding for both visits can sometimes present challenges, so it’s important to get the scoop on how to best handle this scenario from a coding standpoint.

Evaluate Whether Visits Were Related

Although it’s tempting to report two different codes for the separate ED services, that’s not always the best approach. Some payers will not reimburse you for two related E/M visits on the same date of service. Your first step when making the determination of how to code will depend on whether the first and second visits were related to one another.

For instance, suppose a patient who is on blood thinners presents in the morning with a severe nosebleed. The doctor performs the appropriate history and physical examination, and packs the patient’s nose. The bleeding stops and the doctor discharges the patient. Later that day, the patient returns with increased bleeding. Again, the ED physician performs the relevant history, exam, and lab work. They then repack the patient’s nose.

If you’re billing Medicare, you shouldn’t report two visits for this patient, because the chief complaint was the same both times. Unless the visits are completely unrelated, Medicare prefers that you combine them into one E/M service, using the most appropriate code from the 99281-99285 range.

Additionally in this case, you could report the repeat nasal packing procedure separately with code 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method) or 30903 (Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method). Depending on whether the same physician provided each treatment, you would append either modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) or modifier 77 (Repeat procedure by another physician or other qualified health care professional). Of note, physicians of the same specialty in the same group are “deemed” to be the same provider according to CPT^®.

If the visits are for the same reason and the same provider (or another ED provider from the same group practice) performs both, then you’ll typically roll the documentation for both visits into one ED code for the combined visits.

In other cases, you may be seeing patients for two different problems, and some payers will reimburse you separately for both visits in this scenario. For instance, if a patient presents in the morning after falling off a stepstool and breaking her leg and then comes back again in the afternoon with chest pain, you may be able to collect for both.

The Medicare Claims Processing Manual states in chapter 12, “The Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter.”

Check Payer Guidance

Keep in mind that whether or not the visits are related to each other, different payers may have very specific rules about how to report the separate ED visits.

For instance, Part B MAC Palmetto GBA offers the following recommendation for coders that do report two E/M codes on the same date to describe separate diagnoses: “If the reason for the second visit is an unrelated problem that could not have been addressed in the first encounter, the reason for the second visit must be clearly documented in the documentation field of the electronic claim or as an attachment to the CMS-1500 Claim Form.”

Some insurers want you to switch to a paper claim in this situation. Missouri Medicaid, for instance, states, “If the second ER visit is essentially for the same reason as the first, the hospital cannot bill for it. If the second visit is for a different reason, the hospital can bill for the visit. The two visits must be billed on the same paper claim and the ER notes for each visit attached to it. If the patient has two ER visits on the same day at two different hospitals, whichever hospital submits a claim first will be paid. The provider that bills second will have its claim denied and will have to refile a paper claim with the ER notes attached to it.”

Beware Modifier 27

Some EDs say they bill for multiple ED visits on the same day by appending modifier 27 (Multiple outpatient hospital evaluation and management encounters on the same date) to the ED E/M code. However, modifier 27 does not apply to professional services — only to facility billing. This can be confusing based on the fact that most insurers include EDs in the instructions for the modifier on their fact sheets.

In black and white: Part B MAC WPS Medicare states, “Modifier 27 is for hospital/outpatient facilities to use when multiple outpatient hospital evaluation and management (E/M) encounters occur for the same beneficiary on the same date of service. Modifier 27 is exclusive for hospital outpatient departments, including hospital emergency departments, clinics and critical care.”

This would make it sound like modifier 27 was created almost specifically for ED practices to use, but the payer clarifies further down in the fact sheet that the modifier is restricted to the facility side of the claims process, not the physician side. “Physician practices may not use this modifier,” WPS says. “Report this modifier on the UB-04 Part A claim form or electronic equivalent. This modifier is not valid when submitted on a CMS-1500 form or the electronic equivalent.”

Because ED practices use the CMS-1500 form to report their claims (and are considered physician practices, not facility billers), then modifier 27 does not apply.