ED Coding and Reimbursement Alert

Question: When technicians in the ED perform suturing and the ED physician then checks and approves them, can we bill Medicare for it? What if a resident does the repair, and the ED doctor supervises?


Illinois Subscriber

Answer: For the technicians, the Medicare answer is no. Most of the time, the hospital employs the technicians, which means the facility receives reimbursement from Medicare under Part A - so CMS would not allow you to bill for this procedure.
For the resident, you may bill Medicare for the procedure if you have acceptable documentation that the teaching physician (TP) supervised the resident's work. For minor procedures (three to five minutes), the attending must be present for the entire procedure; for major procedures (longer than five minutes), the attending needs to be present only for the "key portion" of the procedure. See CMS Transmittal 1780 for the complete details regarding teaching physician supervision and billing for services involving residents.

For example, if a patient presented in the ED with an acute exacerbation of asthma, the TP would need to be present for the key or critical components of the evaluation and management service, but he doesn't need to be there for the nebulizer treatments. 

The TP should be able to define the key portions, but he doesn't have to duplicate the resident's progress notes. Instead, he should refer to the resident's notes and state that he reviewed the resident's medical documentation and agrees with the diagnosis.

If the TP was not present for the resident's evaluation of the patient, and the resident did not document a complete E/M service, the TP must bill and document the visit as he would in a non-teaching setting.

Hint: Private payers don't have many of these restrictions, so check with the individual payer if you're unsure.