Don’t try to get paid for a nurse’s work in the ED when the patient doesn’t see a physician.
When two physicians, your emergency doctor and a consultant from your group, provide services during the same emergency department (ED) encounter, you can report the same ED code for each provider — but your claim’s success depends on detailed documentation from both doctors.
Continue reading to learn what E/M codes to submit for emergency department services, even when the provider isn’t assigned to the ED.
Look Beyond the Code Description
When a provider sees a patient in the emergency department, you’ll report an ED code from the 99281-99285 (Emergency department visit for the evaluation and management of a patient, …) range.
Important: Even though these are ED codes, that doesn’t mean only ED physicians can report them. The 99281-99285 codes are not exclusive to the ED physician, says Lynn M. Anderanin, CPC,CPC-I, COSC, ICD10, senior director of coding compliance and education for Healthcare Information Services in Park Ridge, Ill.
Official word: The Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.C states: “Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description).” The physician doesn’t have to be assigned to the emergency department.
Possible to Report 1 ED Code for 2 Providers
Because 99281-99285 are not limited solely to ED physicians, you may have multiple providers reporting those codes for the same patient on the same date of service (DOS). For example, if your ED physician calls a specialist in, you’ll use the ED codes for both providers. Therefore,you could have multiple providers reporting 99281-99285 for the same patient on the same DOS, Anderanin adds.
Example: A patient presents in the ED with abdominal pain. Your internal medicine physician covering in the ED performs an expanded problem-focused history and examination with moderate complexity medical decision making (MDM). He orders an abdominal ultrasound, which shows gallstones with acute cholecystitis and obstruction. The gastroenterologist from your practice is also on call. There is a standing order when patients come in with abdominal pain, that the gastroenterologist also sees the patient. The gastroenterologist performs an expanded problem-focused history and examination with moderate complexity MDM. Then the ED physician notifies the general surgeon on call and admits the patient for gallbladder removal.
Based on the key elements your ED physician and gastroenterologist performed, you will report 99283 (… which requires these 3 key components; an expanded problem focused history; an expanded problem focused Mexamination; and medical decision making of moderate complexity) for both providers.
Choose the Level by Documented Performance
You can only report what you find in the report, so it is critical that your providers document all of their work, especially in a fast-paced ED situation.
“It’s important that ER providers are educated to document their thought processes in the health record,” says Peggy Pugh, RN, CPC, CPC-H, CIPP/G, CCP, president of Coding Concepts in Steubenville, Ohio. “Without a clear, well-written guide to their ‘work up’ and medical decision making, it isn’t always possible to select an E/M code that will represent the actual work involved in the patient-physician encounter.”
How not to do it: A patient comes into the ED where your nurse performs triage but the patient leaves before seen by a physician. Because this may be a common occurrence, CMS says some practices are coding the lowest level of the 99281-99285 range to recoup some of the expense of the visit. This is inappropriate coding.
“The limited service provided to such patients is not within a Medicare benefit category because it is not provided incident-to a physician’s service,” says CMS. Unfortunately, you cannot code for the nurse’s services.
References: To see the Medicare Claims Processing Manual, Chapter 12, refer to www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Refer to questions.cms.gov/ to see all of the current CMS frequently asked questions.
