ED Coding and Reimbursement Alert

Use this method to earn inpatient pay for inpatient services

Just because all inpatient beds are full doesn't mean you can send home from the ED an 84-year-old woman with sepsis. When the hospital is full, the ED picks up the overflow--and the work involved. Don't let your practice's payment reflect an ED visit alone if you are entitled to additional reimbursement.

Prepare for the Trend

Hospitals nationwide are feeling the crunch of budget cuts and rising expenses, and it shows in the emergency department. According to the American Hospital Association, the number of inpatient beds decreased by 39 percent in the past 20 years. And the national nursing shortage doesn't help matters--hospitals having financial difficulties are increasingly staffing their inpatient beds with the minimum number of required nurses.

This lack of workers leaves facilities and nurses unprepared to care for unscheduled patients, such as ED admissions, says Elijah Berg, MD, FACEP, chief operating officer of Medical Reimbursement Systems Inc., an ED billing company in Stoneham, Mass.

A new class of patients: An -ED boarder- is a patient who is admitted to the hospital as an inpatient but who stays in the ED for an extended period because there are either no beds at all or no adequately staffed inpatient beds available to care for that patient. The patient is essentially in a limbo state, admitted and technically the responsibility of the admitting inpatient physician, but still in the ED.

The culprit: -The primary cause of ED boarding is an inadequate inpatient capacity for an ED population that has increasing levels of acuity and complexity,- Berg says. Not only is bed space more limited, but patients are sicker.

Don't Dismiss the Work

Most of the time with these patients, the ED physicians end up providing a great chunk of the care, and need to bill for it. -Even if the hospital has formally transferred the patient's care to an inpatient attending physician, the ED attending physician provides some degree of ongoing care and medical legal liability due to the immediate physical proximity of the patient,- Berg says.
 
Some of these patients remain in the ED for the duration of their admission and never make it to an inpatient bed. The length of stay means your physician may be providing all kinds of services, such as reviewing normal repeat lab tests, giving new medications, and even evaluating new complaints (such as chest pain that's entirely unrelated to the original admission).

May the Best Code Set Win

Often, you-ll have already coded an evaluation and management service (for admitted patients, frequently 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).

For the additional work, you can use the subsequent hospital care codes (99231-99233), says Tracie Christian, BS, CPC, CCS-P, director of coding, technical, and training services at ProCode/The Schumacher Group in Dallas.

Technically, you have the choice between these codes and consult codes (99251-99255). But subsequent hospital care codes don't require the formal written request that consult codes do, Berg says. If you decide to report 99231, 99232 or 99233, remember that there are several requirements for a consult code to be reported.  
 
You need a request documented in the patient's chart for the consult, and a formal written consultative report with history, physical exam, and medical decision-making that distinctly support the level of the consult code chosen.

Meeting the criteria for a consult may be tough because, in the ED, you-ll seldom see a formal request documented in the patient's record, Berg says. Instead, the ED nurse generally approaches the ED attending physician with some concern about the patient.

Watch your back: Because the ED physician's notes will be documented in the inpatient record and not an ED record, make sure you have a system in place to confirm that the note went to the billing company.