ED Coding and Reimbursement Alert

News You Can Use:

Pediatric Codes,OIG

Published on Sat Feb 01, 2003

As we plow forward into 2003, an avalanche of news follows in the New Year's wake and little of it bodes well for the emergency department specialty.

CPT has released its final coding changes, bringing disappointing news for EDs. The HHS Office of Inspector General, a federal watchdog agency, announced what coding and billing compliance issues it is investigating in 2003, and EDs are on the list.

New Pediatric Care Codes Are Not for ED

Despite a glimmer of hope that emergency departments might inherit new, high-dollar pediatric care codes, it now seems likely that these CPT codes will not typically be reported by emergency physicians, says Mike Ganovsky, MD, CPC, CFO, of Greater Washington Emergency in suburban Maryland.

The new pediatric critical care codes, 99293 (Initial pediatric critical care, 31 days up through 24 months of age, per day, for the evaluation and management of a critically ill infant or young child) and 99294 (Subsequent pediatric critical care ...), are now intended for inpatient use in the PICU.

The AMA publication CPT Changes: An Insider's View 2003 states: "Code 99293 is intended to report the admission of the patient 24 months of age or less to an intensive care unit, usually a PICU."

OIG Plans of Note for EDs

The OIG's Work Plan for 2003 warns that it will be sniffing around emergency departments, hunting potential coding fraud:

Watch your reassignment reports. Reassignment, when an individual reassigns his right to bill to someone else, is a notable focus for the OIG, and the benefits reaped for the ED are its specific target, says Bill Sarraille, an attorney at Arent Fox Kintner & Kahn in Washington, D.C. The Medicare reassignment rule states that only individuals who provided a service should bill for reimbursement, with some exceptions, such as employees reassigning their right to bill to their employers, no matter where employees provide the service, he says.

So if your physicians are independently contracted, you can't, under any circumstances, reassign their right to bill to the staffing company that contracts them out, Sarraille says. The independent contractors can only reassign their right to bill to the facility where their services were provided, he says.

Double-check your procedure coding, and coordinate with hospital coders and billers. The OIG's 2003 plan indicates that they see a "disconnect" between procedure coding for outpatient services billed by the hospital (facility fee) and what the physician billed for the same service (professional component), Sarraille says. The OIG last year reported a notable error rate between the code matches, and you can bet they assume overpayments are owed to the federal government, Sarraille says.

As a response to this report and investigation, "it is very important" that facilities and physicians "coordinate" their billing decisions so that each side is aware of the other's billing decisions and code selections, Sarraille says. Otherwise, the feds might find inconsistent coding and point fingers at one or both sides.

Your practice could coordinate coding and billing by simply selecting relevant physician staff to convene with hospital personal to talk about particular coding particularities, Sarraille says. Or, if you want a more extensive effort, you can try some sample reviews to see if procedure codes match up, even if you investigate only three or four services on a quarterly basis, he adds.

You can even request a more "systematic" coordination and suggest that the hospital staff not code until it has a dictated report from the surgeon or the physician for the service, Sarraille says. This method ensures that two different coders select codes based on the same information. "Whatever system you select, it's an excellent idea to make sure that you have coordinated your work," Sarraille says.

Again and again, code radiology claims carefully. Remember when we told you that x-ray interpretation is a sticky ED issue, subject to compliance suspicions? The OIG's warning confirms this speculation. There have been statements of "some concern" by the OIG and other agencies about duplicate interpretations of certain diagnostic tests in the ED, most notably radiology tests, Sarraille says. There is something of a "disconnect" between radiology's position on the issue and the language the OIG has used in the past stipulating who should get paid, he explains. Therefore, the suspicion may concern radiologists more.

Regardless, Sarraille warns all physicians and practitioners to be aware that coordination-of-care issues will be a factor, so watch those x-ray claims closely. Get claims in first, but remember that the physician's separately identifiable, signed, written interpretation must contribute directly to patient treatment and care.