ED Coding and Reimbursement Alert

The rule of thumb for assigning E/M codes in the ED one service per physician, per patient per day has so many "buts" it could choke a pack-a-day smoker.

ED coders must deal with patients who receive multiple services on the same day, or who remain in the ED for long periods of time, or whose patient status changes during their time in the ED. To apply E/M codes correctly for repeat visitors, you must thoroughly understand what a separate service entails, how to use modifier -25, and the definition of a day.

The three examples that follow will help you unravel the mysterious permutations of E/M for multiple visits to the ED.

First, let's look at two radically different services performed on the same day. A patient presents to the ED in the morning with lacerations in the right arm incurred after falling off a ladder while cutting down a tree, e.g., 880.0x, Open wound of shoulder and upper arm; without mention of complication. The ED physician should report the procedure code (e.g., 24341, Repair, tendon or muscle, upper arm or elbow) as well as the appropriate level of E/M visit (99281-99285, Emergency department visit).

Later that day, the same person returns to the ED with a severe headache. The physician has already treated the lacerations, but now conducts a thorough E/M service to determine the headache's cause. Even if the headache is related to the first accident, the second evaluation is clearly distinct and significant, and should include a second E/M code with modifier -25 appended.

Though guidance from CMS on modifier -25 has been out since 2001, confusion still abounds. The service "must meet the definition of 'significant, separately identifiable E/M service' as defined by CPT," emphasizes CMS Transmittal A-01-80 of June 29, 2001. In a nutshell, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when a separate and distinct history and physical were necessary.

In the above example, the services were rendered during two separate visits, but modifier -25 may also be appropriate in a case when the procedures happen at the same time. Because the headache could point to a head injury, says Alice Zentner, RHIA, director of education and outpatient coding at MedGrup, it is "going to require a completely different workup and is probably going to draw a higher level."

Note: The facility side may append modifier -27 (Multiple outpatient hospital evaluation and management encounters on the same date) when reporting hospital resources related to separate and distinct E/M encounters performed on the same patient and provided by the same or different physician(s) in more than one outpatient hospital setting on the same day.

In our last scenario, you could easily identify and code for two separate services rendered. But what happens when there are two ED visits with identical diagnoses? You may be tempted to combine the two visit levels, but be careful: Combining visits isn't the same as bumping them up to the next level.

Take this example: A patient with a known history of cardiac problems and anxiety shows up in the ED with all the symptoms of an impending myocardial infarction (MI). The emergency physician performs a complete workup and diagnoses a panic attack rather than a heart attack. The patient is sent home but comes back later that afternoon again believing that he is having a heart attack. Because of the medical necessity and significant risk involved, the physician must respond to the second incident as if it were a unique event.

In this case, the payer will likely deny the second claim even though medical necessity required the doctor to approach each complaint separately. The surest correct billing tactic would be to examine each chart and combine the history and procedural elements to reach the highest level of specificity. But, Zentner says, you "have to make sure everything is documented to take into account the risk presented to the physician and to the hospital." If the claim is still denied, it may be possible to get paid on appeal.

Simply combining the two visits isn't the appropriate way to determine reimbursement, says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City. "You don't want to say, OK, my first visit is a level two and my next one's a level two, so I'll put them together and make a level four," Thomas says. "But if it is the same problem, we would use both charts to score the E/M service so that you do capture the work associated with both visits."

Suppose a patient comes to the ED complaining of acute back pain. Assessment includes performing an expanded problem-focused history and examination, and medical decision-making of low complexity. The patient receives medication. This visit would be coded at 99282 (level two). Later the same day, the patient comes back complaining of worsening symptoms.

Does this scenario allow you to bill for two separate ED E/Ms? The general rule would dictate "no" unless some significant interval event occurred. If the physician asked, "Has anything happened that may have caused your back pain to worsen since the last time you were examined?" and the patient responds, "Yes, the medication nauseated me, and I hurt myself running to the bathroom," the E/M situation shifts subtly.

Because the negative drug reaction would easily qualify as a significant interval event, the attending physician must evaluate what's happened in the interim to worsen the back pain, and perhaps do another evaluation and make a treatment decision. Cases like these are always going to be difficult, Thomas says. The determining factor has to be whether anything happened since the last visit because "it's pretty common for a patient with nausea or headache to come back three hours later and say, 'My headache hasn't gotten any better' because they have not given the situation time to resolve." Thomas advocates combining the two charts and treating the visits as one encounter.

Another question arises when ED patients transit from one status to another. Often, a doctor sees a patient in the ED, performs a full-fledged ED E/M (99281-99285) and then later decides that the patient is too sick to send home, yet not sick enough to be admitted to the hospital inpatient side, so the patient is put in observation, 99218-99220. It gets sticky because the ED physician cannot bill both the ED E/M and the observation, which is itself an E/M service.

Let's say that same patient continues to deteriorate and the doctor realizes that the patient needs to be admitted to the hospital. Even if the same doctor performed all three services, the physician would only bill the most comprehensive E/M code for the day the hospital admit code. However, if three different doctors carried out the services (e.g., the emergency physician, the hospitalist and the primary-care physician), CPT would allow all three doctors to bill because the "same physician" part of the rule is no longer controlling.

In addition to tracking all the other E/M variables, coders must also watch the clock one in which a day isn't necessarily 24 hours long. Suppose a patient is having a treatment for dehydration that will take eight to 16 hours. Most ED doctors aren't going to be on duty for the full 16 hours, so a second physician will probably assume the care.

Although only one service is being provided, if it transits a calendar day the service automatically becomes eligible for a second E/M code when it's supported by the chart documentation. In this case the rule one E/M code per physician, per patient, per day works to allow increased reimbursement. If the episode crosses to a new calendar day, you can bill another code.