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.

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