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 department visit for the evaluation and management of a patient, which requires these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making

  99282 - ...an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity

  99283 - ...an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity

  99284 - ...a detailed history, a detailed examination, and medical decision-making of moderate complexity

  99285 - Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity.

Use Common Sense

Your best bet in these situations may be to decide on a case-by-case basis whether to bill for the second E/M, says Paul C. Jesionek, MD, MBA, FACEP, FAAEM, chairman of emergency medicine at Robinson Memorial Hospital and vice president of Physicians Emergency Services, both in Ravenna, Ohio.

"If the repeat visit somehow results as a consequence of a perceived lapse in medical care or evaluation (which isn't usually the case) or a callback - for example, a change in radiologic interpretation - then we do not bill for the second visit," Jesionek says.

But suppose that a patient who had an identified kidney stone before an ED encounter presents to the ED for pain from the stone. The ED physician adequately treats the patient during this encounter, and the patient improves and goes home. Later that day, the patient has another episode of the pain, and returns to the ED for care. In this case, you should bill for both visits, Jesionek says.

Beware Modifier -27

Modifier -27 (Multiple outpatient hospital evaluation and management encounters on the same date) might look like a tempting alternative if your payers are denying claims with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the second E/M code. But don't fall for it: Modifier -27 does not apply to professional services, only to facility billing, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Deer Park, Ill.

Even if your ED physicians are employed by the hospital, modifier -27 still isn't appropriate, Gilhooly says. The employment arrangement should never affect billing for physician services, with the exception of the tax ID number that goes on the claim form, she says.