ED Coding and Reimbursement Alert

Nurses often perform minor procedures in the Emergency Department under the supervision of the physician. Many coders wonder whether these services can be reported on the physicians bill since he or she ordered the procedure and supervised its performance.

The answer in most cases is no.

It is a controversial area, although it neednt be, says Gregory L. Schnitzer, RN, CPC, CPC-H, CCS-P, an audit specialist in the Office of Audit and Compliance at the University of Pennsylvania Health System.

Many of these procedures, which ED physicians are billing for actually are performed by nurses or other ancillary personnel, often have zero physician work relative value units (RVUs) assigned because it is understood that somebody other than the physician will be performing these tasks.

The total RVU values assigned to these procedures are often comprised of the office expense/overhead and malpractice expense component RVUs, with no actual work values assigned, he explains. The RVU value is designed to compensate the physician offices for their expense in performing the procedure.

Procedures commonly performed by nurses in the ED setting include:

therapeutic injections (90782-90799);

starting IV administration of medication (90780-90781) or, for thrombolysis infusion (92975-92977, coronary vessels; 37195, cranial vessels);

urine catheter insertions (53670*, catheterization of
urethra, simple);

removal of impacted ear wax, (69210); and

splint and strap applications (codes found in the Surgery/Musculoskeletal System/Application of Casts and Strapping 29000-29590).

For Medicare carriers and payers who follow the Medicare RBRVS, if the procedure is assigned zero physician work RVUs, then the emergency physician will actually see no reimbursement for this procedure even if it is reported.

It is sort of a moot point in that situation, Schnitzer notes. The site of service is always indicated on the bill. If the patient is seen in the hospital, the carrier knows not to include any practice overhead payment because the treatment is not delivered in an office setting.

However, some codes used in the ED do have physician work RVUs but are often performed by the nurse, but are occasionally done by the physician.

CPT codes are to be used for physician-provided services, adds Jackie Davis, president and CEO, of Term Billing, Inc., an emergency medicine billing company based in Arlington, TX. We do not report procedures when they are performed by nurses, unless there is documentation that the physician was there supervising the patient at the same time. And, really, the only reason the physician did not perform the procedure is that he or she was occupied performing some other task for the patient at the same time.

For example, the CPT definition for diagnostic or therapeutic infusions by IV specifically states that the physician must either perform the infusion or it must be performed under direct supervision of the physician, indicating that the physicians presence at the bedside satisfies the definition of this code.

Incident To Does Not Apply in Hospital

In physician offices, procedures performed by nurses are filed on the physicians billing form. This is allowed because the physician employs the nurse and the nurses salary is coming out of the physicians office budget.

For a physician to bill for a service that he himself did not personally render, the service and the procedure would have to meet incident to guidelines, which include the mandate that the ancillary person performing the task be employed by the physician, the facility where it is performed must be leased or owned by the physician, and that the service be an integral, but incidental part of the physicians overall service, Schnitzer notes.

However, Medicare has ruled that the entire concept of incident to billing is invalid in any hospital setting, including the ED.

Schnitzer says he understands that physicians feel they should be compensated for supervising the nurse provider, but that Medicare rules state otherwise.

Some Commercial Carriers Pay for Supervision

Some commercial payers may be willing to reimburse the emergency physician for the work of supervising the hospital nurse who performs the procedure, even if the physician is not physically present.

For example, notes Schnitzer, some private payers reimburse the emergency physician for thrombolytic administration, even though Medicare does not and has assigned no physician work RVUs for this service.

There are two schools of thought on this, Schnitzer advises. Some feel that if Medicare will not pay for it, it is wrong to bill it to anybody else. Then, there are others that say that whatever policies and procedures the individual payer wants to put in place, that is how the procedures should be coded and billed to that payer.

Some groups find it overly cumbersome to keep track of different payer reimbursement policies and only report codes for services and procedures that are reimbursable by all payers. Schnitzer notes that many groups, particularly smaller emergency medicine practices, cannot afford to do this.

In my opinion, if something were not allowed to be coded and billed to Medicare, you could still legitimately bill it to another payer, he says.