ED Coding and Reimbursement Alert

Question: Can we bill for E/M services in the ED if the patient is admitted? Because Medicare will pay for only one E/M service per day, if the ED physician bills one level E/M and the attending physician admitting the patient bills another E/M, how does the ED get paid?

Montana Subscriber

 
Answer: The key to payment is specialty designation and the particular E/M codes selected. For the E/M coding, the ED physician will use the appropriate codes in the 99281-99285 series (emergency department services), while the admitting physician will use the 99221-99223 series (initial hospital care). Because the ED physician and the attending physician are of different specialties, both physicians will be paid for professional services that are reasonable and necessary. When the attending physician begins the credentialing process for Medicare in the state in which the physician wants to practice medicine, part of the process includes choosing the specialty designation. Medicares list of physician codes contains 63 specialties. The appropriate specialty designation is essential to proper payment. If your claims are denied, check with Medicare to make sure the specialty designation is correct.
 
In some states carriers do not recognize specialty 93, emergency medicine. On occasion, when reviews are performed, it is found that the ED physicians have been placed in specialty groups with family physicians or internists. This may prevent bills from being paid or affect the statistics on codes and procedures performed because some carriers will not allow certain specialties to bill certain codes.