ED Coding and Reimbursement Alert

An ambulance from your hospital responds to a report of an automobile accident. The ED physician answers the EMS staffs call for medical direction. In addition to getting information on the number of injured who will be transported and the seriousness of the injuries, the physician provides clinical guidance to the EMS personnel, instructing them on the administration of medications and advanced resuscitation measures. Can the physician bill for the supervisory services via radio, i.e., the medical direction of ambulance and EMS personnel?

According to CPT, this is a recognized service reportable with its own code99288 (physician direction of emergency medical systems [EMS] emergency care, advanced life support). However, because this service does not involve actual face-to-face contact with the patient, Medicare does not acknowledge this as a physician service and will not pay for it, says David McKenzie, physician reimbursement manager for the Dallas, TX-based American College of Emergency Physicians (ACEP). The Health Care Financing Administration [HCFA] has assigned no physician relative value units to this code, he relates.

Dont Report to Medicare

Language contained in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) has been interpreted by some health information experts to indicate that reporting a code to Medicarethat HCFA specifically states it will not coveris a form of fraud, says McKenzie. Although not everyone agrees with that interpretation, he recommends against reporting the code to Medicare.

This leaves the question of whether or not to bill the code to private payers.
It is certainly providing a CPT-recognized medical service to the patient and incurring medical/legal liability, both of which, I think, deserve to be compensated, McKenzie notes.

Practical/Ethical Dilemma

However, many ED groupsfor both practical and ethical reasonscode professional services the same way for all payers. One, it involves much more record keeping and paperwork to keep up with specific payer coverage policies. Two, many groups oppose coding based on payment policy and not strictly on the service provided.

I have always been pretty strongly of the opinion that, other than for payers whose payment policies you are legally obligated to follow, you shouldnt tailor your bill based on what you know the payer is going to pay, McKenzie states.

Of course, this perspective requires recognizing that there are certain codes that will be covered by some private payers and not by others. Groups ordinarily can report the same codes to all payers, accepting payment from the ones that cover it, and writing off as debt the charges for patients covered by other plans and pursuing collection for the ones that dont.

However, with HIPAA, physicians are between a rock and a hard place with Medicare.

You have the same scenario with the administration of thrombolytic therapy, says McKenzie. It is a very real service that is provided by the physician, but Medicare doesnt pay for it. But those payers that do pay, often pay very well and you would be leaving a lot of money on the table not to bill at least some payers for it. The question of how to bill private payers for these instances will have to be settled by each individual group as it believes best, he advises.

Code Requirements

If you do choose to report 99288, there are some guidelines to follow, says Todd Thomas, CPC, a former EMS professional who is now an emergency medicine coding consultant, president of Thomas and Associates in Oklahoma City, OK, and former president of the
Oklahoma chapter of the American Academy of Professional Coders (AAPC).

If you do bill 99288, the physician should reflect in the chart what his involvement with the EMS group was, Thomas notes. Usually, the ED physician has some amount of EMS direction in every case because they wont show up at a facility without calling ahead first. What the payers are really looking for when you report 99288 is that the EMS personnel encountered the patient, had some sort of clinical situation that they werent sure how to handle and needed the ED physicians help. Just the basic, OK, sounds good, well see you here in 10 minutes isnt really what they are looking for with this code.

In many cases the service might even be considered part of the total evaluation and management (E/M) service if the patient is then seen in that ED, McKenzie adds.

The tricky part of that is where does your pre-service for your E/M code start and medical direction stop? he asks. Many payers choose not to recognize more than one E/M service per patient per day, unless a significant separate problem were reported, almost forcing you to bill this service only when you are providing EMS direction and the patient either dies en route or is sent to another facility. The latter situation does happen, Thomas notes.

Sometimes EDs go on divert, which means that they cant take certain kinds of patients or they cant take any patients, Thomas explains. For example, the hospital may go on neuro alert, when there is no neurologist on call or the one on call is in surgery or maybe the CAT scan machine is broken. So, that hospital will divert patients with neurological injuries to other hospitals. The ambulance and staff transporting the patient would still be under the original doctors medical direction until arriving at the other facility.

Tracking Codes Internally is Important

Even though you dont report the code to Medicare, and may choose not to report it to private payers, ED coders should still enter the code into their system with a zero charge attached, says Thomas.

You might want it for informational purposes, to track the services that the ED physician is providing, he explains.
Many managed care plans, and some hospitals, track the productivity levels of the physicians with whom they contract. Often the only way to know how many patients per hour the physician averages is to track the number and frequency of CPT codes billed.

If this code is not recorded because it is not charged, then the time the physician spends providing medical direction (which may be significant in certain cases) is not accounted for, he adds.

Plus, if you keep accurate track of how often this service is provided and what services are provided during medical direction, it gives us more ammunition to go to the powers that be [and appeal] and say, This service happens a lot. Reflected by these numbers, we feel we should get paid for this service.