ED Coding and Reimbursement Alert

You Be the Coder:

Midlevel Providers

Published on Tue Aug 01, 2000

Question: We have a fast track/urgent care facility that is considered a clinic within the walls of our hospital as part of our emergency department (ED). When we have midlevel providers perform services here, are we required only to code them out as 99281? Our ED physicians are employees of the hospital and our hospital does the physician billing. We have the same price charged for 99281, 99282 and 99283. We use this as a marketing tool to be competitive with other walk-in care areas in town. Is it correct to code out the different codes and still have the same price?

Lori Seriacki
Manitowac, Wis.

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Answer: Individual payers may have unique guidelines governing how services of midlevel providers are to be billed. In general, however, you should select the evaluation and management (E/M) code that most closely describes the service rendered. Remember to use the midlevel providers unique provider number when billing Medicare and certain other payers as required. Although your physicians are employees, you do not tell us the employment or independent contractor status of your midlevel providers, which may affect how their services may be billed. You may want to review the detailed Health Care Financing Administration (HCFA) guidelines for billing of midlevel providers.

The prices you set for your fees are really irrelevant. But you should be billing the proper E/M service based upon the documentation in the record the physician has provided. The carrier will need to know that based upon documentation, the E/M service billed is reflected.

The charge is your responsibility, and if you bill the same amount for your 99281-99283 level of service to attract business, thats appropriate. But many times the costs associated with the higher levels of service do not cover the services being provided and need readjustment. You should leave that to the administrators responsible for the fee schedule and to contract negotiators.

If you do not bill the appropriate E/M codes, the carrier will be getting a false impression of the acuity of your facility. This has had disastrous results in the past whereby hospitals that coded only one level or completely ignored certain codes were viewed as having never performed that service or else had a low acuity.