ED Coding and Reimbursement Alert

ED practices may leave thousands of dollars on the table each year by applying Medicare coding regulations to all payers. CPT guidelines differ in several crucial areas, and coders who understand the differences can have a big impact on the bottom line.

"Practices are absolutely losing revenue if they are not applying CPT rules when submitting claims to private payers," says Jim Blakeman, senior vice president for coding quality assurance with Healthcare Business Resources Inc., in Bala Cynwyd, Pa. "In addition, they are violating rules established to govern AMA coding."

"This is an extremely important distinction," agrees Peter Sawchuk, MD, president of Eidos Healthcare Resources in Green Pond, N.J. "On average only about 20 percent of the patients seen in the ED are Medicare beneficiaries. This means that up to 80 percent of the services might be reportable according to CPT rules."

What follows is an explanation of some differences between CMS and CPT in several essential areas.

Codes 99234-99236 (Observation or inpatient hospital care) are assigned when patients are admitted to and discharged from observation on the same calendar date. Medicare requires, however, that the patient remain under observation for at least eight hours for these codes to apply. Under Medicare rules, if a patient remains under observation for fewer than eight hours, but is nonetheless admitted to and discharged from observation on the same calendar date, the ED physician assigns only an observation admission code (99218-99220, Initial observation care). No discharge from observation code (99217) would be reported.

Conversely, CPT coding instructions state that codes 99234-99236 should be used "to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service." In other words, CPT doesn't require an observation stay to be eight hours or more in order to report codes 99234-99236 as Medicare does, Sawchuk says.

Coders should note that some local Medicare carriers follow CPT coding instructions and allow ED physicians to report codes 99234-99236 when a patient is admitted and discharged on the same day, regardless of the amount of time spent in observation or inpatient hospital care.

Medicare's fee schedule for any given service factors in care provided during a global period, Blakeman says, which covers a range of 0 to 90 days surrounding the service, depending on the type of procedure performed. Payment for the procedure then includes routine care (both before and afterward) related to service.

CPT, on the other hand, doesn't recognize global periods. It uses a surgical-package concept to define specific services like an E/M service the same date as the procedure, digital blocks and routine follow-up care that are considered part of a procedure.

Note: Medicare also recognizes these services as bundled into the surgical code.

But here, CPT and Medicare part ways. Some CPT codes are identified with an asterisk (*) in the CPT manual to indicate that the service is considered a "starred" procedure and is exempt from the surgical-package concept. When reporting these procedures (e.g., 10120*, Incision and removal of foreign body, subcutaneous tissues; simple), you may also assign codes for other services that would be considered part of the surgical package for nonstarred procedures, e.g., office visits or related procedures.

It's important to know this difference, Blakeman says. "Coders should not apply Medicare guidelines to private payers because it may prompt them not to report a service that may be payable."

For example, if a practice followed Medicare reimbursement rules for 12001* (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less), which doesn't allow payment for follow-up care within its 10-day global period, it would not report the office visit for suture removal even when billing a private payer. This would cause a loss of income because the visit would be permissible under many private-payer guidelines.

The differences between global packages and surgical periods have other repercussions, Blakeman says. Medicare considers even complications part of the original procedure and does not pay for follow-up care during the surgical period. "If the patient is seen because a laceration that was repaired three days earlier is infected, Medicare would not pay for the follow-up. CPT rules, however, allow this visit to be billed independently of the original procedure (e.g., 99281, Emergency department visit) because the infection classifies as a complication."

It's not widely recognized, but you can assign both an ED visit code and a critical care code (i.e., 99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes; and +99292, ... each additional 30 minutes [list separately in addition to code for primary service]) for a patient on the same day. Both Medicare and private payers will reimburse these encounters if properly documented but Medicare is pickier about how they are reported.

"CMS requires that the noncritical-care E/M service occurfirst. If the conventional E/M servicedoesn't precede the critical care service, the critical care service probably won't be paid," Sawchuk says. "With private payers, the order shouldn't matter. Either servicemay occurfirst."

Coders often wonder if pulse oximetry (e.g., 94760, Noninvasive ear or pulse oximetry for oxygen saturation; single determination) can be coded separately or if it is a component of the ED visit. Again it depends on the payer: Medicare considers the interpretation of pulse oximetry bundled, while CPT guidelines allow it to be billed separately, Blakeman says. But it must be billed with modifier -26 (Professional component only) and only when a separate, distinctly identifiable, signed written report is prepared. This is also the case with ventilation management (e.g., 94656, Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day) and EKG interpretations (93010, Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only), he adds.

Given these policy differences, Sawchuk says, coders should do all they can to determine if a particular patient is covered by Medicare or a private payer, and know the various payers' reporting policies. "The coding and subsequent payment may be quite different. Of course, if you can't identify the payer, it might be wiser to select the more conservative coding method."