ED Coding and Reimbursement Alert

Simple solution eases multiple-visit chaos

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 who is 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 should you report the work the physician has done without selling your practice short? Heed Different Rules for Different Payers The first thing you need to know when deciding how to code these visits is which payer is footing the bill.

Private payers: CPT rules allow reporting of a separate evaluation and management service for each visit consistent with the documentation provided. There is significant private-payer discrepancy on requirements for a modifier in this scenario, so check with your individual carriers to find out their policies, and consider appealing denials.

Additionally in this case, you could report the repeat nasal packing procedure separately with code 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) or 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing], any method). Depending on which physician provided each treatment, you would append either modifier -76 (Repeat procedure by same physician) or modifier -77 (Repeat procedure by another physician).

Best bet: Discuss this choice with your practice group, because some groups may opt not to bill for the second visit if it results from an initial treatment failure.
 
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 different chief complaints, says Debra Williams, CPC, coding supervisor at Horizon Billing Specialists in Grand Rapids, Mich.

For example, if a patient presented to the ED in the morning with abdominal pain, received treatment, and returned in the evening with a sprained ankle, you could report two separate encounters.

In the nasal packing scenario above, because the service took place in the ED, the patient probably 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. Unless the visits are completely unrelated, Medicare wants you to combine them into one E/M service, using the following codes:
 
  99281 - Emergency [...]