ED Coding and Reimbursement Alert

Because emergency medicine is ripe with learning opportunities, many medical students and residents complete part of their training in the ED. While beneficial to education, these relationships open the door for fraud and abuse when coders don't understand how to report care provided by these healthcare professionals.

"Simply put, most services rendered by a medical student cannot be billed" (see Classifications of Providers in box below), says Jim Blakeman, senior vice president for coding quality assurance with Healthcare Business Resources Inc., in Bala Cynwyd, Pa. The only services performed by a medical student that can be used in documentation are the history of the present illness (HPI) and review of systems (ROS), which can be recorded by any ancillary personnel and referenced by the physician as to review and agreement. "Care provided by residents is billed under the attending physician's name and provider identification number (PIN), but only if specific requirements are met."

Failing to meet these requirements results in serious consequences, he adds. Not long ago, Medicare expected noncompliant ED practices to repay only overages received. "Now they are also assessing fines and penalties. The largest penalty assessed was levied against the University of Pennsylvania several years ago and totaled $30 million. It's vital that physicians at teaching hospitals (PATH) and those who code their services understand the limitations," Blakeman says.

Medicare has established the standard for reporting resident services, he says, with distinct rules for E/M services and other procedures or services. Other payers may not adopt these regulations. Medicaid, for instance, has not. "Because this varies greatly payer by payer," he notes, "ED physicians and coders should check with each insurer to determine the proper reporting methods."

According to Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City, attending physicians must meet two criteria in order to code residents' E/M services: "The attending or teaching physician must be physically present in the ED and must repeat important portions of each of the three key components of an E/M."

For instance, he says, a 9-year-old is brought into the ED with high fever, sore throat and vomiting. The resident examines the child, orders a strep test and diagnoses strep (034.0, Streptococcal sore throat). The attending also sees the patient. During face-to-face time with the patient, the teaching physician duplicates a segment of the history or HPI, examines the patient for the significant symptoms, and repeats a portion of the medical decision-making process.

"These activities must be clearly documented," Fick says. "The attending must leave a 'thumbprint' on the chart. He or she must clearly state, 'I was present' and outline the key portions of the visit that were repeated. The notes must be patient-specific and cannot simply say that the attending concurred with the resident." When these services are performed and adequately documented by the teaching physician, ED coders should assign the appropriate level of E/M service (e.g., 99283, Emergency department visit).

In addition, Blakeman says, the attending must tether his or her statements to the resident's notes. "There must be a clear reference to the resident's work. For example, the teaching physician might record, 'My attending service was conducted in conjunction with resident X.'"

Medicare has specific rules for other procedures a resident might provide. Again, the attending must be present in the ED. However, since there are no key components governing non-E/M services, a second set of criteria comes into play.

"If a service requires five minutes or less, it is considered a minor service," Blakeman says. "For minor procedures, the attending must be physically present and standing next to the resident for the entire service. Many carriers refer to this as 'elbow-to-elbow' supervision since it is not adequate for the teaching physician to simply be in the room. He or she must be at bedside, watching the resident perform the entire service."

For major procedures those requiring more than five minutes the attending must document that he or she was present or performed the key portion of the procedure. "For instance, if the resident is repairing a laceration (e.g., 12053, Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm), the attending may document that he or she was present and personally probed the wound for debris," Blakeman explains. "In these cases Medicare allows the teaching physician to determine what the key portion of the procedure was."

He adds that no rules govern differences between an attending's being "present" as opposed to "performing" part of a major procedure. "Either may be documented and, as far as I know, no carrier makes any reimbursement distinction between whether the physician personally performed a key portion or if he or she was simply present," Blakeman says.

Two areas of service cause specific coding problems. Fick notes that ED practices often can't bill admission services if an attending from another service takes over when a patient is admitted.

"For instance, a patient arrives at the ED in labor, and the resident and ED attending care for her," Fick says. "An ob attending takes over and admits the patient into his or her service (e.g., 99222, Initial hospital care) when it is clear the patient requires admission. The ED faculty wants to bill for its care in the ED, but the ob writes the notes that link to the resident's notes. Therefore, the ob faculty can bill the admission. With only one resident note, the ED attending cannot also link to that same note."

Blakeman adds that critical care is often a missed revenue opportunity for ED faculty. Because it is not strictly viewed as an E/M service with key components or as a major or minor procedure, it can't be classified as other PATH services are. Medicare requires that the attending physician perform critical-care services and does not pay for resident-provided critical care. "Critical care encompasses a lot of bedside attention, which residents frequently provide," he notes. "Faculty assume therefore that they can't report critical care. However, they are forgetting that critical-care time also includes talking to the resident about the patient's care, calling a consulting physician, reviewing and documenting in the chart, and looking at lab results, films or rhythm strips. If these activities are documented as taking longer than 30 minutes, the faculty member can bill the critical-care code (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)."

Many coders point out that after their first year of residency, residents are licensed physicians and may bill their services directly in some settings. Blakeman explains that when residents are caring for patients under the auspices of a teaching entity, Medicare regulations do not allow them to bill directly. "Medicare pays teaching entities a fee through Part A to provide education to residents," he says. "They don't want to pay twice for residents by also reimbursing professional fees through Part B. So, unless an attending physician actually performs the service, Medicare won't pay for the care."