ED Coding and Reimbursement Alert

Question: Can we bill for care provided while patients are being transported by EMS?

Answer: You can separately report transport services if the code conditions are met. Patients in the emergency department frequently need transfers to or from another venue to receive the care they need. The emergency physician is often involved in these transfers, but not all of that work is separately reportable from the ED E/M service.

It is common for a physician in the ED to provide medical direction via radio to EMS personnel in the field. A code exists for this service, 99288 (Physician or other qualified health care professional direction of emergency medical systems [EMS] emergency care, advanced life support).

To report this code, these must be transports of an emergency nature requiring advanced life support rather than a routine transfer, or even transporting a patient from a nursing home to the emergency department for a routine checkup. CPT^® says that the code is intended to cover the direction of necessary medical procedures including but not limited to: telemetry of cardiac rhythm, cardiac or pulmonary resuscitation, endotracheal or esophageal obturator airway intubation, administration of IV fluids, or administration of intramuscular, intratracheal or subcutaneous drugs and electrical cardioversion.

However, code 99288 has no RVUs assigned and is frequently not covered by payers. They consider it to be part of the preservice work of the E/M service when the patient does arrive in the ED and the physician takes over the patient’s care. In the less likely event that the radio direction is for a patient that does not come to the ED where the physician is working, there is no face-to-face encounter so that service has historically not been reportable either.

The situation is different when the emergency physician is actually present during the patient transport, especially for pediatric and neonatal patients.

There are specific codes in the CPT^® book for transporting critically ill or injured pediatric patients under two years of age requiring the physical attendance and direct face-to-face care by a physician during the interfacility transport. These are 99466 (Critical care face-to-face services, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; first 30-74 minutes of hands-on care during transport) and 99467 (…each additional 30 minutes [List separately in addition to code for primary service]).

These require face-to-face care, which starts when the physician assumes primary responsibility of the pediatric patient at the referring facility, and ends when the receiving facility accepts responsibility for the pediatric patient’s care. You can only report the time the physician spends in direct face-to-face contact with the patient during the transport, so any time spent traveling to the transferring facility to collect the patient cannot be counted towards the minimum time threshold.

Pediatric patient transport services involving less than 30 minutes of face-to-face physician care should not be reported and any procedure or service performed by other members of the transporting team may not be reported by the supervising physician.

There’s A Code For For Directing A Pediatric Transfer Without Face-To-Face Time

If there is not face-to-face care for the critical  pediatric transfer patient, but the physician is directing emergency care through outside voice communication to transporting staff personnel, those service can be  reported using, 99485 (Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes two-way communication with transport team before transport, at the referring facility and during the transport, including data interpretation and report; first 30 minutes) and 99486 (…each additional 30 minutes [List separately in addition to code for primary procedure]).

Report supervision: Understand that codes 99485, 99486 are used to report the control physician’s, (meaning the one directing the transport service), non-face-to-face supervision of interfacility pediatric critical care transport, which includes all two-way communication between the control physician and the specialized transport team prior to transport, at the referring facility and during transport of the patient back to the receiving facility.

Because 99485 is a timed code, the established thresholds must be met. Code 99485 is used to report the first 16-45 minutes of direction on a given date and should only be used once, even if time spent by the physician is discontinuous. Services of 15 minutes or less cannot be reported, says Granovsky.