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. Same-Date Observation:Time Is Crucial Difference 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. Global Surgical Periods:Get Paid for Additional 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 [...]