ED Coding and Reimbursement Alert

See if you can spot the errors in these examples

If you think your emergency department (ED) isn't receiving all the reimbursement it deserves (hint: most EDs aren't), inspect these expert-supplied bills carefully to see if you can stop denials in their tracks.
 
Bill #1: A Medicare patient presents in the ED with a stiff neck, headache, vomiting, and fever. The ED physician ordered intravenous (IV) NS, 25 mg of IV Demerol, 12.5 mg of IV Phenergan, labs, and a computed tomography (CT) scan of the head. She consulted a private physician who performed a spinal tap in the ED.

What's wrong with the top bill example?
 
Answer #1: This bill contains several major slip-ups, says Caral Edelberg, CPC, CCS-P, president of Medical Management Resources in Jacksonville, Fla. The first: the coder should have included the spinal tap (62270 - Spinal puncture, lumbar, diagnostic), using revenue center 450, even though a private physician performed the procedure and not the ED doctor.
 
In addition, while the coder billed the correct IV injection codes under revenue center 450, she also needs to list the medications on the bill: Demerol (J2175) and Phenergan (J2550) under revenue center 250 (Pharmacy). This revenue center also applies to the J7030, normal saline, although some payers may accept the 260 (IV Therapy) as well, says Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C. According to the April 4, 2000, edition of the Federal Register (page 18497), you should be sure to list drugs even if they're not separately payable under the outpatient prospective payment system (OPPS), because services under revenue code 250 apply to outlier payments.
 
Also, always remember to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the evaluation and management (E/M) code when applicable, says Edelberg, who presented on ED coding at the American Academy of Professional Coders 12th Annual Conference. In this case, Q0081 (Infusion therapy, using other than chemotherapeutic drugs, per visit) and 66270 have status indicators "S" and "T," which make the latter subject to reduction and allows you to append modifier -25 to the E/M code.
 
Furthermore, the CT scan of the head, although another department performed it, should be reported with one of the following codes, depending on whether contrast was used: 70450 (Computed tomography, head or brain; without contrast material), 70460 (... with contrast material(s)), or 70470 (... without contrast material, followed by contrast material(s) and further sections). You shouldn't report the two lab codes, 80050 (General health panel) and 80051 (Electrolyte panel), together unless the staff needed to repeat certain tests, Goodman says. "All of the services in the electrolyte panel (80051) are included in the general health (80050) panel," she says.
 
Bill #2: An 80-year-old female fell at a nursing home and injured her right wrist. She presented in the ED, and the physician ordered a wrist x-ray series and found no fracture. He administered IV Demerol and Phenergan for pain. He then applied an ice pack and sent her back to the nursing home.

What's wrong with the middle bill example?

Answer #2: The trouble here: you can only append modifier -25 to an E/M code - in this case, 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity) - when you're also reporting a separate CPT code with a status indicator of "S" or "T."
 
The wrist x-ray series, represented by code 73110, has status indicator "X," and the medications have status indicator "N," Edelberg says. Therefore, you shouldn't append -25 to 99283. The x-ray should also appear with revenue center 320 (Radiology-Diagnostic), Goodman says. "Revenue center 255 refers to drugs incident to radi-ology services rather than the procedure itself," she says.
 
Additionally, the IV injections of Demerol and Phenergan should be reported with 90784 (Therapeutic, prophylactic or diagnostic injection (specify material injected); intravenous) rather than 90782, which is for subcutaneous or intramuscular injections.
 
Bill #3: An elderly male is driving his car and runs into a telephone pole. He arrives at the ED unconscious. The physician ordered c-spine, wrist, and skull x-rays. She then started an IV and gave a bolus of fluid, ordered labs, and administered one amp of D-5 IV. The patient, who was suffering from low blood sugar, then woke up, and the physician placed a short arm splint on his left wrist.

What's wrong with the bottom bill example?

 
Answer #3: This bill has several missing items, Edelberg says, including a missing E/M code with modifier -25 appended. The coder also failed to list the IV fluid (normal saline is code J7030) or D-5W under pharmacy revenue center 250.
 
Additionally, the lab tests mentioned are missing from the claim, and the x-rays should appear with revenue center 320 (Radiology-Diagnostic), Goodman says.
 
Note: Code Q0081 has been phased out for 2005. You are correct to report these services on this claim, however, since you provided the therapy in 2004.