ED Coding and Reimbursement Alert

Every emergency department (ED) knows the story. Emergency medical technicians (EMTs) bring in a male patient with chest pain (786.5 series), nausea (787.02) and dizziness (780.4). Soon after entering the emergency department, the patient goes into cardiac arrest (427.5).

Technically, the EMTs are relieved of responsibility once they bring the patient to the hospital, but in reality they often lend a hand, according to John Turner, MD, PhD, medical director for documentation and coding compliance, healthcare financial services at TeamHealth, a physician staffing firm in Knoxville, Tenn. Frequently they will assist, if the patient is critical. But thats basically from the goodness of their heart; they dont have to do it. Its not in their job description. In some cases, if they didnt come in and help us, wed be behind the eight ball when it gets very busy.

Some coders run into problems determining codes for procedures performed by emergency medical services (EMS) personnel inside the hospital. A rule of thumb is that unless the EMTs are employed by the hospital, they usually dont bill for services after the patient reaches the emergency department.

The ED staff bills as soon as the staff takes over, says Caral Edelberg, CPC, CCS-P, president of Medical Management Resources Inc., an emergency medicine coding company in Jacksonville, Fla. As long as the ED physician and staff are involved, they can bill for it.

The same principle applies to the facility side, Turner says, because any services EMS performs inside generally will use the hospitals equipment. Once treatment is provided at the hospital, hospital charges apply.

Say a patient comes in full arrest with active CPR (92950, cardiopulmonary resuscitation), Edelberg says. EMS brings the patient into the code room, and doctors and nurses take over. The facility level will reflect that.

That said, both facility and physician coders must be cautious. Documentation of EMS is often spotty because the EMTs normally arent involved in any of the record keeping, although there are exceptions.



Hospital Rules Take Precedence

Although most metropolitan hospitals contract EMS services, many hospitals, particularly in rural areas, have their own EMS division, Turner says. If the hospital runs its own EMS service and employs the EMTs, that hospital must have its own way of billing for their services, and coders should be aware of the hospital-specific rules.

In general, hospitals cant bill for the work performed by emergency medical technicians, Turner says. But its not a major portion of the procedures done in the hospitals. Its just a friendly gesture.

If an EMT administers an antibiotic (90788, intramuscular injection of antibiotic [specify]) or attaches a splint to a broken finger (29130-29131, application of finger splint), the hospital cant bill for it. Although it sometimes happens, no hospital wants to depend on paramedics to perform these services, regardless of whether they can get paid for them. But by far the most frequent overlap between EMS and emergency department services occurs when EMTs perform CPR.

Although coders should be aware of who performs every service and the documentation should contain that information, coding for CPR is the same regardless of who actually performs it, Turner says. Frequently what happens is the hospital orderlies or nurses or the physician is doing CPR. They physically need bodies to do compressions, and EMS may help out if theyre tired.

Hospital coders should bill for CPR regardless of who performs it, as long as an ED doctor is in charge. The physician bills the CPR code under his or her own number. Physicians can bill for CPR specifically in the ED, Turner says. The physician is directing everything that happens. In most arrests Turner has seen, the doctor participates in some portion of the mechanics, whether its performing compressions or bagging the patient. But even if the physician isnt taking part in the CPR, he or she can still bill. Thats because the physician is telling the others where to put their hands, how fast to compress, how fast to bag, and when to stop to monitor.

Remote Control

When physicians direct the actions of EMTs in the field, coders must handle the case differently, although the coding is fairly simple. If EMTs call on the radio and a physician directs treatment, he or she can bill under 99288 (physician direction of emergency medical systems [EMS] emergency care, advanced life support), Turner says. The trick with that is that you cant bill just because the ambulance team calls in saying that they are bringing in a woman with a broken hip (820.8). If the doctor makes treatment decisions, directs to another hospital for different treatment, or chooses medications, then he or she can bill. The key for coders is documentation.

Not everyone pays 99288, Edelberg says. Medicare and many private payers always deny the claims. Turner adds that some groups pay a low reimbursement, and some pay pretty well. This code is missed frequently and could generate significant revenue for ED groups.