ED Coding and Reimbursement Alert

Alcohol and drug intoxication have caused enough damage to your patients don't let these coded diagnoses block reimbursement for your ED.

What you don't know could hurt reimbursement rates. So watch out: Your payers may have a provision that allows them to deny claims with alcohol and drug codes. Health insurance policies sometimes deny medical reimbursement to patients under the influence of drugs or alcohol, states a Wall Street Journal article printed Feb. 26, 2003, "Why Emergency Rooms Rarely Test Trauma Patients for Alcohol, Drugs." These policies, based on state insurance laws, keep some physicians from running drug or alcohol tests for fear of losing reimbursement on procedures done for trauma patients, the article says. (See "Check Your State's UPPL Laws" in article 5 for a list of states that have these laws, and where you can find them.)

Do not be intimidated by these legalities. Report alcohol and drug intoxication diagnoses if your physician documented them. You will usually get paid, especially if the patient had other reasons for coming to the ED. The following additional pointers will help you stave off lost reimbursement from these diagnoses. Trauma Comes Before Alcohol,Drugs The first set of codes you should report for trauma victims should describe the main reason they presented to the ED, usually injuries, says Nettie McFarland, RHIT, CCS-P, coding manager at Healthcare Billing Systems Inc. in Daytona, Fla. List the alcohol and drug codes as secondary diagnoses. The first set of diagnosis codes, such as the injuries, will support the need for any procedures in addition to your E/M codes, she adds.You will almost always get paid for claims with two sets of diagnosis codes: injuries and then substances. In Michigan, health insurers pay about 50 percent of alcohol-related motor-vehicle accidents, the common culprit in trauma cases, and auto insurance the other 50 percent, says Sandra Pinckney, at Certified Emergency Medicine Specialists in Grand Rapids, Mich. "In these cases, we have never once been denied because of the alcohol."

Here are two typical examples of trauma victims who present to the ED with injuries and the presence of intoxicating substances. Following each scenario is the correct way to code it.

Example #1: EMS brings to the ED an unrestrained driver in a motor-vehicle accident (MVA). At the scene of the accident is a starred windshield, most likely from when the patient's head hit it. The patient complains of chest pain (likely from hitting the steering wheel) and has no or little recollection of how the accident progressed. There's a possibility that alcohol is involved. The physician performs a thorough exam neurologic, chest, cardio, respiratory, etc. The diagnoses for this case should be a head injury, such as 959.01 (Head injury, [...]