ED Coding and Reimbursement Alert

Question: We are a level-1 trauma center with a burn unit that operates around the clock. Patients who cannot be treated locally due to the extent and severity of their burns go directly to the burn unit for treatment. Can an ED code be used for these patients? HCFA and AMA guidelines define an emergency facility as an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. Ive been told that the area has to be licensed as an ED. Is this the case?

Lorraine A. Began, CPC
Metrohealth System, Cleveland

Answer: The answer may depend on how the payer interprets the level, as well as the place, of service.

Per the introduction to the ED section of CPT 2001, The following codes are used to report E/M services provided in the ED. No distinction is made between new and established patients in the emergency department. An emergency department is defined as an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day [emphasis added].

The reference to the provision of services in the ED indicates that the services should be provided within the confines of the ED. Often payers adapt unique criteria for certain categories of services, and therefore your questions should also be addressed to your local carrier and fiscal intermediary. If the ED codes dont apply, the outpatient clinic codes might although if the patient registers in the ED, he or she would be considered an ED patient unless otherwise required by payer guidelines.