EM Coding Alert

Don't assume only ED physicians can use 99281-99285.

If you've ever wanted to learn what you should and shouldn't do when coding for evaluation and management (E/M) services in the emergency department (ED), don't delay. Now is the perfect time to brush up on your ED E/M coding skills.

To get the lowdown on what's up with ED E/M coding, check out this list of coding do's and don'ts before you report your next ED visit.

Do Understand What Sets the ED Apart

According to the CPT^® 2017 manual, an ED is an "organized hospital-based facility" that provides unscheduled, sporadic services to patients who require immediate medical attention. An ED must be open 24 hours a day.

To report E/M services provided in the ED, you will use 99281-99285 (Emergency department visitfor the evaluation and management of a patient, which requires these 3 key components ...). Unlike with other E/M codes, E/M codes for the ED do not distinguish between new and established patients.

Don't Count On Time

Although you may consider time a descriptive component for determining the correct level of E/M services in other situations, this does not hold true for E/M services in the ED. In fact, when the American Medical Association (AMA) overhauled the E/M section in 1992, the American College of Emergency Physicians (ACEP) pushed for the time element to be removed from the ED codes, according to Todd Thomas, CPC, CCS-P, president for ERcoder, Inc. in Edmond, Ok.

"Emergency department services are provided on a variable intensity basis, involving multiple encounters with several patients over an extended period," says Thomas. "Due to the complex nature of the workflow in the emergency department, it would be difficult for physicians to provide accurate estimates of the time spent face-to-face with the patient."

Do Use 99281-99285 for Any Physician

It's a common misconception that only ED physicians can report ED services (99281-99285); but, in truth, any physician can report an ED code if he provides a service for a patient registered in the ED. Therefore, the physician does not have to be assigned to the ED, says Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb.

Thomas also reiterates this fact about which physicians can use 99281-99285, but he also mentions an exception to the rule.

"If the patient's personal physician asks the patient to meet them in the emergency department as an alternative to the physician's office," says Thomas. "In these cases, the physician should bill the appropriate office/outpatient visit codes."

Don't Use 99281-99285 When Other Codes Are Appropriate

Although physicians use 99281-99285 to report most ED patient encounters, in some special cases, CPT^® has assigned more specific codes you should turn to, even if the physician performed the service in the ED.

If the physician provides critical care services, look to 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or 99292 (...; each additional 30 minutes [List separately in addition to code for primary service]).

If the physician admits the patient to the hospital, you should use 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...;)

If the physician performs any observation services, use:

• 99218-99220, Initial observation care, per day, for the evaluation and management of a patient...
• 99234-99236, Observation of inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date...
• 99217, Observation care dischargeday management.

Do Recognize Complexity Associated With ED Coding

Sometimes coders who have limited ED coding experience may find it difficult to understand the complexity of identifying the appropriate treatment or diagnosis in the ED, says Thomas.

"Inexperienced coders and auditors will often assign an E/M code based on their interpretation of the severity of the final diagnosis when it should be assigned based on the severity of the presenting problem," adds Thomas.

Thomas goes on to give an example: A patient presents to the ED with chest pain. The patient receives a complex cardiac workup to identify and treat or rule out a life-threatening cardiac event. By the end of the encounter, the final diagnosis may be something like indigestion or gastritis, which does not sound severe enough to warrant a 99285 (Emergency department visitfor the evaluation and management of a patient, which requires these 3 key components ...).

However, according to Thomas, you should not base the code on the final diagnosis, but rather the presenting problem and the work you did to arrive to the final diagnosis. Medical necessity should be the over-arching criteria. If you needed to perform all of those tests and you used complex decision making to come to the conclusion that the patient had indigestion, that should not negate the work that went into getting to the final diagnosis.

Do Emphasize Importance of Staff Development

Training, communication, and consistency are vital to your success as an ED coder.

"You must provide ongoing feedback to physicians, practitioners, and applicable staff regarding coding, billing, and medical record documentation requirements for the reporting of emergency department services," says Swanson. "You must also perform internal and external chart reviews of emergency department services to determine accuracy of reporting."

Swanson mentions the importance of creating consistent policies.

"To assist in compliant reporting and billing of emergency department E/M services, it is important to establish internal policies and procedures outlining guidelines specific to physician Emergency Department E/M billing and coding," says Swanson.