ED Coding and Reimbursement Alert

Question: Do I have to find a record of an x-ray being ordered on the documentation template, or can I use the ED order sheet to get my physician one point in the "complexity of data to be reviewed" element of the E/M service? I have been sending the claims back to ED physicians for them to note on the template the ordered x-ray. Should I keep doing this?

Virginia Subscriber

Answer: No, you do not have to keep sending the template back. The physician order sheet should be acceptable for capturing the one point for ordering the test, which counts toward the medical decision-making component of the E/M claim.

To bill for the x-ray interpretation separately and not as part of the E/M service, you need to include a separately identifiable report, similar to a specialist in the field. In addition, to get the two points for independent visualization, you should have a clearly identifiable separate report similar to a specialist in the field to be safe. Some experts feel that the physician need only document an independent review. This style of documentation might work best for computed tomography scans or other studies not routinely billed for by ED physicians.

You Be the Coder and Reader Questions reviewed by Mike Granovsky, MD, CPC, CFO, of Greater Washington Emergency in suburban Maryland.