ED Coding and Reimbursement Alert

Question: A patient who is unable to communicate clearly and to explain her medical problems presented to the ED. Her condition prevented the physician from obtaining a complete history of present illness (HPI) and ROS from her. Therefore, the doctor could not develop a definitive assessment. He called the patient’s previous physician to discuss her medical problems. Including face-to-face patient time (45 minutes) and telephone calls (45 minutes) to other providers, the doctor spent a total of 90 minutes on this patient on the same day. How should I charge for this scenario? Which E/M codes and modifiers should I use to justify the extra time that the doctor spent on the phone on this patient’s behalf?

Codify Subscriber

Answer: You should bill the scenario based on the appropriate level of E/M service (99281-99285, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components…). Time is not a factor for selecting E/M codes in the ED, so you cannot report an E/M code based on time in this situation.

The physician may document the excessive effort of trying to get an appropriate history with the reason for excessive effort and a reason for why he was unable to obtain the full history. The physician may receive credit for the “unobtainable” history.

Although tempting for the physician to report service time when the patient is not physically present, you cannot report this time to most payers. Of note, an exception would be if the patient met the requirements for critical care, then the time spent discussing the patient’s care with other medical professionals could be counted towards your total critical care time reported.

Payers consider extra time, as noted in the example above, to be part of the pre- and postservice work associated with the payment for the evaluation and management service. If you submit a charge for this extra time to a payer that does not cover the service, the carrier may hold the patient responsible for the fee.