ED Coding and Reimbursement Alert

Question: Are E codes mandatory in Arizona, and if so, why? We are using them, but our billing department would like to drop them.

Arizona Subscriber

Answer: Although typically not mandated, E codes provide a clearer picture for the insurance carriers if applied appropriately. The more explicit a claim, the easier it should be to get it paid. If you have additional information relating to the cause of the patient's visit or injury, submit this information with the initial claim rather than waiting for the insurance company to request it from the patient.
 
Arizona's Medicare carrier, Noridian Mutual Insurance Company, applies this policy for E codes particularly when they are used for therapeutic purposes:
 

Do not code directly from the Table of Drugs and Chemicals. Refer to the tabular list for code selection
 

Use as many codes as necessary to describe the drugs, medicinal or biological
 

Should the same E code be used to describe the agent for more than one adverse reaction, apply the E code only once
 

If two or more drugs, medicinals or biologicals are documented, be sure to code each individually unless a combination is available
 

When a reaction results from the interaction of a drug and alcohol, use poisoning and E codes for both
 

If the reporting format limits the number of E codes that can be reported, use the E code related to the principal diagnosis
 

If there are different fourth-digit codes in the same three-digit category, use the code for "other specified." If there are no "other specified" categories, apply the code for "unspecified"
 

If the codes are in different three-digit categories, assign the E codes for "other multiple drugs and substances."
 
Third-party payers are making increasing demands for justification of treatment. In other words, they expect the physician to establish medical necessity by matching diagnosis codes to services provided. The use of ICD-9 codes is required on government claims per the Medicare Catastrophic Coverage Act. Failure to include ICD-9 codes on assigned claims may result in denial of payment.
 
E codes are supplemental and are never used as the primary diagnosis. The primary diagnosis is the reason for the service or procedure provided. Additional information such as the circumstances of an accident, place of an accident or cause of injury can be reported using E codes. ICD-9 guidelines suggest coding all diagnoses to the highest level of specificity. This would include coding any circumstances involved in the reason for the procedure or service.
 
Even when payers don't require E codes or have trouble accepting them, the codes could be applied for informational tracking purposes. For example, if a facility or a physician wanted to know how many injuries are classifiable to accidents or external causes, using E codes allows that information to be tracked. If those codes are never applied, one could never know how many of those patients are seen. For example, although Medicare and Medicaid do not reimburse 99050-99054 (after-hours/Sundays/holidays) some EDs code them to determine how many patients were seen after-hours or on Sundays for staffing purposes. Any mandates relating to Arizona should be verified through the state medical society or local Medicare carrier.
 
For detailed E code guidelines in your state, go to www.lmrp.net.