ED Coding and Reimbursement Alert

Payer policy will likely determine the correct strategy

Confused about the rules regarding multiple ED visits with the same date of service? Check out the results of this sample case for guidance.

Here’s the situation: A patient on Coumadin presents to the emergency department (ED) with epistaxis.  . 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. He then repacks the patient’s nose and gives her vitamin K. How do you report the work the physician’s done in the second encounter?

Heed Different Rules for Different Payers

Be sure you know the policies of the payer involved before deciding how to code these visits, especially if you have a contractual arrangement, says Michael A. Granovsky MD, CPC FACEP, President of LogixHealth a national coding and billing company in MA.

Private payers: CPT® rules would allow reporting of a separate ED E/M service for each visit consistent with the documentation provided. There is significant private payer discrepancy on requirement for a modifier in this scenario, so check with your individual carriers. Additionally the repeat nasal packing procedure could also be coded. Correct modifier application would involve using 76 (Repeat procedure or service by the same physician or other qualified health care professional) or 77 (Repeat procedure by another physician or other qualified health care professional). Discuss this with your group as some groups may opt to not bill for this second visit if it results from an initial treatment failure,” Granovsky adds.

Medicare: Medicare may be a different story, depending on the specifics of the case. Technically, Medicare does allow you to bill for two separate E/M services, but in order to do so and get reimbursed properly; you’ll have to jump through a few hoops. For starters, each visit must be based on distinct and different chief complaints, warns Granovsky.

For example, consider a patient seen in the morning for abdominal pain who returns in the evening with a sprained ankle.

In the nasal packing scenario above, because the service took place in the ED hours apart, the patient might have received treatment from two different physicians. But if you’re billing Medicare, you shouldn’t report two visits for this patient, because the chief complaint was the same both times. Additionally Medicare deems two physicians of the same specialty in the same practice as being the same provider. Unless the visits are completely unrelated, Medicare wants you to combine them into one E/M service, using the following codes:

• 99281 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem focused history, a problem focused examination, and straightforward medical decision making)

• 99282 (…an expanded problem focused history, an expanded problem focused examination, and medical decision making of low complexity)

• 99283 (…an expanded problem focused history, an expanded problem focused examination, and medical decision making of moderate complexity)

• 99284 (…a detailed history, a detailed examination, and medical decision making of moderate complexity)

• 99285  (Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history, a comprehensive examination, and medical decision making of high complexity)

Use Common Sense

Your best bet in these situations may be to decide on a case-by-case basis whether to bill for the second E/M. If the repeat visit somehow results as a consequence of perceived lapse in medical care or evaluation (which isn’t usually the case) or a callback — for example, a change in radiologic interpretation — then  Medicare will not expect to make payment for the second visit, says Granovsky.

But suppose that a patient who had an identified kidney stone before an ED encounter presents to the ED for pain from the stone. The emergency physician adequately treats the patient during this encounter, and the patient improves and goes home. Later that day, the patient is involved in an MVA and brought to the ED by ambulance. In this case, the visits are distinct and unrelated, adds Granovsky.

Don’t Be Tempted By Modifier -27

Modifier 27 (Multiple outpatient hospital evaluation and management encounters on the same date) might look like a tempting alternative if your payers are denying claims with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the second E/M code. But don’t fall for it: Modifier 27 does not apply to professional services, only to facility billing, warms Granovsky.

Even if your ED physicians are employed by the hospital, modifier 27 still isn’t appropriate. The employment arrangement should never affect billing for physician services, with the exception of the tax ID number that goes on the claim form, he says.