ED Coding and Reimbursement Alert

4 tips help you select the right code to describe services provided outside the emergency department.

Emergency physicians can be called out of the ED to attend to patients elsewhere in the hospital. Sometimes, especially in rural areas, the emergency physician is the only doctor in the hospital after hours to treat emergent or urgent problems such as falls or patients who code. Because these services are provided outside of the emergency department, the ED E/M codes 99281-99285 don't apply. Apply these four coding solutions from Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a medical coding and billing company in Bedford MA, to better describe common inpatient services that your ED physicians perform.

1. Consider Critical Care

If the patient meets the definition for critical care and minimum time thresholds are achieved, you can report code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). Critical care is not specific to use in the ED, the ICU, or a designated critical care area of the hospital. In some ways this is the least complicated code choice, since its documentation requirements are the same in any setting.

Document carefully and don't forget to report any separately billable procedures, such as endotracheal intubation, CPR, or placement of central lines, as long as the procedure times are clearly deducted from the reported critical care time without dropping below the minimum thirty minute time threshold. The chart documentation might look something like this:

"Called urgently to see a 66 year old female status post hysterectomy with severe shortness of breath and recent post op diagnosis of pulmonary embolus. Arrived to find patient in cardiac arrest. Intubated by me with a 7 French ET tube at 23 cm at the lip. CPR under my direct supervision with resumption of vital signs (see code sheet). Following this pressors started including dopamine with review of blood gas and repeat lab panel. Following stabilization Care turned over to the patient's primary care physician who arranged for transfer to the ICU. I provided 35 minutes of critical care in the support of this patient outside of separately billable procedures and outside of any CPR time."

On the claim report:

• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). Append modifier 25 to 99291
• 31500 (Intubation, endotracheal, emergency procedure)
• 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest])

2. Assess Whether Subsequent Hospital Codes Justified

If the patient's needs don't meet the requirements for critical care, the subsequent hospital visit codes 99231-99233 are likely the correct choice. These codes are available to providers other than the admitting physician who provide care to the patient during their inpatient stay.

Keep in mind: CPT® rules are different for E/M codes outside the ED. Of note, only two of the three key components need to be met for this code family. Besides the history, physical exam and medical decision-making components of subsequent care codes, time is also an "explicit factor" in selecting the most appropriate E/M service. Times listed in the subsequent hospital code descriptors are average for floor/unit time rather than face to face time as in office or other outpatient service codes.

Review the CPT® descriptors carefully before selecting these codes:

• 99231 -- Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity....Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.
• 99232 -- Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity ....Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.
• 99233 -- Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity...Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit.

Sample documentation:

"The physician documentation showed that he was called to the inpatient floor to see a 37-year-old female admitted for severe tonsillitis and sinusitis who had developed a significant nose bleed. Due to the patients obesity she had been started on prophylactic anticoagulation. The notes reflected that the patient appeared in moderate distress with active significant epsistaxis from the right nare and elevated blood pressure. The physician performed an expanded problem focused history and physical exam including review of the labs, platelet count, and coagulations studies. Following application of significant direct pressure for 10 minutes the bleeding abated. Orders were written for an additional dose of her blood pressure medicine and the physician then returned to the ED."

On the claim report 99232.

3. Determine If Inpatient Consultation Codes Apply

Although Medicare has stopped recognizing inpatient consultation codes (99251-99255), they still appear in the CPT® book and may be available for use with other payers if the requirements are met. These rules include performing the services at the request of another physician, issuing a formal report and typically returning care back to the original requesting provider. These requirements set a fairly high bar and meeting all the conditions will rarely be true for the emergency physician being called to the inpatient area to treat a patient.

Sample documentation:

"Received a consultation request from the psychiatrist on duty for the inpatient psychiatric unit to see a 23 year old female who had become agitated and drank some dishwashing liquid from the coffee bar area on the unit. The patient's vital signs were stable and though agitated she was in no respiratory distress. Expanded problem focused H&P showed no indications of dangerous reactions. A call to the poison control center proved the product was not toxic. I monitored her vitals until labs returned showing normal levels. A report was dictated for the psychiatrist and care returned to him for continued evaluation of this apparent suicide gesture. Total floor time was 38 minutes."

On the claim report 99252 (Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient's hospital floor or unit).

4. Report Procedures Only

Sometimes due to the circumstances involving floor visit scenarios, no E/M service is adequately documented. Even so, consider reporting any procedures provided, as long as an adequate chart note is available. Procedures such as CPR or laceration repairs might still be reportable with an adequate procedure note even in the absence of meeting the requirements for reporting a formal E/M service. (See the accompanying box for some procedure-only reporting options.)

"Called to the inpatient floor to assist the hospitalist running a code on a crashing heart patient and asked to place a central line while he managed the other aspects of critical care. Triple lumen catheter inserted through a right internal jugular approach without complication. Good flush and return in all 3 ports. Care continued by the hospitalist. I inserted the central line only, verified placement and returned to the ED since we had single coverage."

In this case you would report only 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older)

Bottom line: Keep your eyes open for critical care as this is one of the cleanest ways to report these floor services. Additionally, note typical procedures such as central lines, chest tubes, and intubation.

In many circumstances when an E/M service is documented, the ED physician will report a subsequent hospital visit code from the 99231-99233 code set for "floor response" E/M services.

Because floor visits aren't documented right in the ED record, be sure to develop a chart flow operational mechanism to capture the services rendered by your emergency physicians outside the ED, says Granovsky.