ED Coding and Reimbursement Alert

Because of the nature of its services, the emergency department (ED) rarely duplicates the efforts of other facility departments. No other medical field routinely sees patients without appointments and handles emergency situations off the street. But when the ED draws on the services of other hospital departments, overlaps occur. Many of these overlaps pose serious coding and billing problems. Coders should be especially careful when billing for test interpretation, evaluation and management (E/M) services, consultations and services provided by multiple physicians.

Legally, ED doctors can bill for any service they perform, according to John Turner, MD, PhD, medical director for documentation and coding compliance, healthcare financial services at TeamHealth, an ED staffing firm in Knoxville, Tenn. But other physicians involved in the process also can make a legitimate case for reimbursement, and this can lead to billing problems.

Areas Where Overlaps Occur

Most ED physicians read many x-rays and electrocardiograms (EKGs) (93000-93010), and would like to bill for them. The trick is the hospital radiologist and cardiologist depend on this for a large portion of their income, and they dont want to lose it, Turner says.

Cardiologists and radiologists routinely charge full price for looking at tests that already have been reviewed in the ED, Turner says. Specialists occasionally will spot a nodule on a chest x-ray (71010-71035) that could indicate the beginning of cancer, while the ED physician was looking for a collapsed lung (518.0), broken rib (807.00-807.19) or something else trauma-related. Turner says similar situations happen often enough to justify the practice of specialists overreading charts.

But when both doctors bill for interpreting the same test, only one person can be paid. Ken DeHart, MD, president and CEO of Carolina Health Specialists physician group in Myrtle Beach, S.C., is a former chair of the American College of Emergency Physicians (ACEP) coding and nomenclature committee and a past member of the American Medical Association (AMA) CPT-4 editorial panel. He calls the issue of x-ray and EKG interpretation a rapidly evolving controversy. The Health Care Financing Administration (HCFA) has directed hospitals to develop their own guidelines. But if they are unable to do so, and if two bills are submitted for payment, carriers have been directed to pay the physician who provided the interpretive service concurrent to the patients treatment.

In most cases, that means the ED physician should be paid. But thats not how it always works out. If theres a chronological lag between the bills, Medicare will pay the first physician to bill, but the other physician can appeal. If they appeal, fiscal intermediaries (FIs) have been given directives to pay the doctor who provides services contemporaneous with the patients treatment, says DeHart. But it doesnt end there.

At that point, coders inadvertently become involved in a turf war. If the ED group gets paid, the hospital radiologists and cardiologists are likely to complain because they werent paid. In these cases, only physicians and administrators can solve the problem.

Coders should be prepared and know the policies of each hospital or physician group they work for. To resolve disputes, compromises have been reached. Some hospitals allow ED doctors to bill during the hours when the specialists arent in. Some ED groups dont bill for interpretations at all. Some physician groups have won concessions from a hospital and always can bill. Whatever the situation, coders can avoid controversy simply by knowing who gets billed for what and ensuring that they code correctly.

Test interpretation isnt the only area of overlap in the ED. Here are some other potential pitfalls:

E/M Services

The AMA CPT-4 editorial panel maintains that a physician can submit only one evaluation and management (E/M) bill for a patient on a particular date, according to DeHart. That creates a problem for services such as observation (99234-99236), which use the same section on the claim form and require the same components a patient history, physical exam and documentation of the decision-making complexity. Many coders dont realize that they cant code both an observation and a visit code (99281-99285) for the same doctor treating the same patient on the same day.

These E/M quandaries are amplified at small, rural hospitals, for example those that have fewer than 12,000 visits. The ED physicians may admit patients and care for them until the next morning, simply because there isnt a staff physician to admit them. Coders cant use 99285 (emergency department visit for the evaluation and management of a patient) for stabilization in the ED and then add any of the 9922x series admission codes. Ironically, it would be completely admissible if another physician came in and admitted the patient, DeHart says.

Consultations

Interdepartmental consultations arent overly problematic. If an ED physician calls in a surgeon to check whether a patient has appendicitis (541), thats technically a consult, Turner says. The ED physician bills the visit code (99281-99285), and the surgeon bills an outpatient consultation (99241-99245). When an emergency physician is called to consult in an inpatient ward, he or she simply can bill 99251-99255 (initial inpatient consultation for a new or established patient), depending on the complexity of the assessment.

To qualify as an outpatient consultation, the visit must meet three requirements:

1. The treating physician must request the consul-tation, typically in writing.

2. The consulting physician must provide a written eport. This should feature documentation of a patient history, physical exam and the complexity of medical decision-making, according to the CPT requirements for each consult level code.

3. The consulting physician cannot significantly participate in the principal care of the patient.
If the consulting physician later participates in the patients management, he or she can use the codes for subsequent hospital care (99231-99233).

Multiple Physicians

According to CPT, any doctor can use any appropriate code, but many payers will recognize only one code for an individual service, regardless of the difficulty of the situation and how many physicians were necessary for treatment.

If the two doctors involved are from different specialties, some payers may allow both to bill. Medicares policy of no concurrent E/M services doesnt apply to physicians with different specialties.

For doctors who routinely do the same kind of work, the issue of overlapping services remains sticky. You cant have two physicians from the same group or specialty coding for the E/M service, Turner says. You have to make a decision about who did most of the work.

Coders can compensate for this by billing the visit or critical care code for one doctor and billing the procedure for the other, but if both physicians are responding to a cardiac arrest (427.5), theres no way to avoid choosing one over the other.

Some patients acuity may require more than one physician. Confusion can exist regarding which physician was most necessary, says DeHart. He cites the example of a multiple-trauma cardiac arrest.

A patient comes in after a motorcycle accident, and the trauma team is mobilized. The ED physician reaffirms cervical immobilization, initiates nasotracheal intubation, and conducts a primary and secondary survey. He then splints a fractured tibia (823 series) and begins diagnostic studies, including a CAT scan of the head (70470) and abdomen (74170).

The trauma surgeon then reads the CAT scan and sees signs of a ruptured spleen (289.59). The patient becomes hemodynamically unstable and is taken to the operating room, where the trauma surgeons partner takes over.
In this case, both the ED physician and the trauma surgeon may have provided constant attention for the critically injured patient. Where does that leave them? Payers may not deny the issue of critical care, but they may not pay both physicians.

Coders can best try to make up for the difference by billing critical care for one doctor and reimbursing the other through a high-complexity visit code such as 99285, if the documentation supports it. When all else fails, coders should remember the appeals process, DeHart advises. If the critical-care components are met, its worth a try.