ED Coding and Reimbursement Alert

Question: If an Orthopedic resident comes to the ED and reduces a fracture while my emergency physician is present, can I charge for the procedure? The Orthopedic resident sometimes speaks with the Orthopedic attending who is not present, and may only consult by phone. The Orthopedic attending may or may not follow the patient after the ED encounter.

The ortho group usually does not charge for the ED reduction performed by residents. As a result, there is money left on the table. I am liable for any mishap. At another site, which is a non-teaching hospital, we personally perform similar procedures, and we bill for the procedure. So these procedures are within our scope of practice and we are licensed and do them within our hospital network.

Even if the orthopedic resident is performing the procedure, can we bill for the procedure given our presence and management of the case?

Illinois Subscriber

Answer: You may bill for the reduction performed by the resident you supervised if the service is within your scope of practice and you meet and document the supervisory requirements. The orthopedic attending could not report the service since he was not present or directly participating in the care.

Medicare’s Transmittal 2247 offers these instructions:

“For purposes of payment, E/M services billed by teaching physicians require that they personally document at least the following:

That they performed the service or were physically present during the key or critical portions of the service when performed by the resident; and

The participation of the teaching physician in the management of the patient.”

In order to bill for surgical, high-risk, or other complex procedures, the teaching physician must be present during the critical or key portions of the procedure and be immediately available to furnish services during the entire procedure.

A phone call from the resident to the orthopedic attending does not meet the physical presence requirement and it would be a stretch to claim that as participating in the management of the patient during the procedure. 

You should not bill for the procedure when the orthopedic resident staffs the case along with the Ortho attending who is also present in your ED. However, the orthopedic attending being somewhere else in the hospital does not count as being physically present and immediately available.

Of note: You’ll still need to add modifier 54 (Surgical care only) if you’re not providing the full global service as spelled out in the CPT^® descriptor or global period term.

Tip: Verify that the orthopedic group is not also billing the service or you could face audit problems for both you and your teaching program.