ED Coding and Reimbursement Alert

Many ED physician groups staff the emergency departments at different hospitals, and see patients covered by many different health plans. In addition, emergency medicine billing and coding companies may submit claims for groups in different cities and different states.

Billing requirements and policies often differ from payer to payer. Some pay for conscious sedation, some consider it bundled into the procedure. Some recognize modifiers, some dont, or only recognize a few. Even Medicare carriers have different policies in different regions, our sources report.

In North Carolina, in the ED or any new patient visit, Medicare doesnt want to see the -25 modifier on an E/M when a procedure is performed, says Pat Moore, vice president of reimbursement for Healthcare Business Resources, Inc.(HBR) in Durham, NC. They expect you to bill an E/M code and a procedure, but they tell you not to use the modifier because it will bounce out on their edits for having too many -25 modifiers. But, in Florida, we have to use the -25 modifier for Medicare.

Setting up a strict coding policy that doesnt take these differences into account can mean lost revenue and even lost payer contracts.

To keep track of different policies and ensure that their physicians get accurately reimbursed, Moore has set up a system called Coding Considerations at HBR.

We keep a log for every one of our clients, with sections on all of the payers they contract with, listing whether they pay for conscious sedation or dont, or whether they pay for x-ray and EKG interpretations separately, etc., she explains.

When a coder takes a chart, they look at the considerations listed for that payer and that specific physician group.

The system is comprised of a set of three-ring binders that is maintained by a specific set of staff members at HBR.

In the binder, in addition to the coverage information, we have the back-up for that instruction, whether it was a Medicare bulletin or a list of diagnoses for Medicaid that that carrier will pay as a bona fide emergency, she says. All of that is in the back of the book. And, anytime new information comes in, we all [upper management] signs off on it and then it is added to the books.

This system allows coders to easily tailor their coding to the specific payer requirements, saving money and lost time spent on appeals, she says. When someone is coding our charts, they have the coding considerations right there and can say, I wont report the conscious sedation code because this payer doesnt pay.