ED Coding and Reimbursement Alert

Question: A patient reported to the emergency department (ED) at 7 a.m. for fever, nausea, and vomiting. The ED physician treats the patient and sends them home. At 5:30 p.m. that same day, the patient reports again for worsening symptoms. Can you report two ED evaluation and management (E/M) codes for these encounters, or do you combine the two services and choose a single ED E/M?

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Answer: Medicare will not pay for two ED E/Ms for the same patient on the same calendar day. For these patients, you should combine the work of the two ED E/Ms and then choose a code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set that best represents the service. You should also append R50.9 (Fever, unspecified) and R11.2 (Nausea with vomiting, unspecified) to the ED E/M to represent the patient’s symptoms.

Possible exceptions: While Medicare won’t pay for two ED E/Ms on the same day, some private payers might — if the patient presents for two distinct problems. Private payers will likely deny two ED E/Ms for the same symptoms, however, like the scenario in your question.

So, for example, let’s say a patient reports with fever, nausea, and vomiting at 7 a.m., and the ED physician treats them and sends them home. Weak with fever, the patient falls in their home and sprains their right ankle. There is no mention of the patient hitting anything when they fell. At 5:30 p.m. that afternoon, the patient returns to have their ankle examined.

This could result in a pair of ED E/M codes, but you need to check each private payer contract separately.

Remember: If two visits are billed for the same day, medical necessity supported by ICD-10 coding for the two visits is important. Also, be certain that chart documentation supports both visits. So, if you are reporting two ED E/Ms for the example above, you’ll append R50.9 and R11.2 to the first E/M code, and S93.401A (Sprain of unspecified ligament of right ankle, initial encounter) and W01.0XXA (Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter) to the second code.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC