General Surgery Coding Alert

Many coders are unaware that, under CMS and CPT rules, any physician can report 99281-99285 for emergency department (ED) services. Just as important, however, you must know that the ED service codes are not your only choice in these situations.

Depending on the circumstances and the strength of the available documentation, you may be better off to claim a consultation, admission service, or even critical care.

When reporting ED services (99281-99285, Emergency department visit for the E/M of a patient -), keep three key points in mind:

1. You may report 99281-99285 only for physician services provided in the ED.

An ED, as defined by the Medicare Internet Only Manual (IOM, Publication 100-4, Chapter 12, Section 30.6.11B), is "an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention." CPT defines an ED similarly as "an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention."

You should not report 99281-99285 for services (even "emergency" services) the physician provides in the office or outpatient setting other than an ED.

2. You can report 99281-99285 even for non-emergency services provided in the ED. "The only requirement for using the emergency department codes is that the patient be seen in the emergency department for an unanticipated service," the IOM states.

3. Any physician -- not only those assigned to the ED -- can report 99281-99285.

Medicare's IOM specifically states, "Any physician seeing a patient in the ED may use ED visit codes for services matching the code description. It is not required that the physician be assigned to the emergency department to use ED visit codes."

Not all private payers follow the same rules: Some non-Medicare payers may insist (in defiance of CMS and CPT guidelines) that only ED physicians can use 99281-99285. If this is the case, be sure to get the payer's recommendations in writing, and follow them to the letter.

You should not limit your choices to 99281-99285 for services your surgeon delivers in the ED.

For instance, if the physician admits the patient to inpatient status, you would report the initial hospital visit codes (99221-99223, Initial hospital care, for the E/M of a patient -; or 99234-99236, Observation or inpatient hospital care, for the E/M of a patient including admission and discharge on the same date ...) in place of an ED services code.

Similarly, if the physician admits the patient to observation status subsequent to the ED service, you should report only the appropriate observation care code (99218-99220, Initial observation care, per day, for the evaluation and management of a patient -; or 99234-99236).

In addition, if the service the physician provides meets the criteria for a consult, you will report the appropriate-level outpatient consult code rather than an ED service code, according to the IOM (Publication 100-04, Chapter 12, Section 30.6.11F).

Remember: The ED is an outpatient -- not an inpatient -- setting.

Example: A patient with head injuries from an auto accident arrives in the ED. The ED physician requests a consult from your surgeon to evaluate for possible abdominal trauma. The surgeon provides the E/M service and shares his findings with the ED physician.

In this case, the surgeon should report the appropriate-level outpatient consultation code (for example, 99244, Office consultation for a new or established patient -). Although this service occurred in the ED, it meets all the consultation requirements (a request and reason for the consult, a review of the patient's case, and a report of findings back to the requesting physician), and you may report it as such.

Alternative scenario: If, however, the surgeon chooses to admit the patient, he will report only the appropriate initial hospital care code for his services (for example, 99222). You would not report a consultation and hospital admission for the same problem on the same day. Rather, the hospital admission covers all E/M services the physician provides on the same date of service (IOM, Chapter 12, Section 30.6.11F).

In December 2006, the AMA's CPT Assistant clarified that you may report an E/M service and critical care if the surgeon performs both during the same session, says Jim Blakeman, senior vice president at Emergency Groups Office in Arcadia, Calif. To avoid denials, however, you should include separate documentation for each service.

Example: A patient with epigastric pain with associated nausea and vomiting presents to the ED. The physician performs a comprehensive exam and takes a complete history, which reveals a negative cardiac history. The physician orders labs and an abdominal series. The radiologist reports the abdominal series as negative. The physician gives the patient IV narcotics and anti-emetics, and after re-evaluation the patient states she feels better.-

But due to lingering concerns, the physician arranges admission for more testing and serial abdominal exams.

While awaiting admission, the patient collapses. The surgeon starts CPR and intubates the patient. The surgeon resuscitates the patient and determines that she had an acute myocardial infarction (MI). He starts the patient on nitroglycerin and lidocaine drips and performs multiple re-evaluations and consultations with other providers.-

The physician spends 60 minutes of noncontinuous time (excluding the time spent supervising CPR and performing the intubation) tending to the patient after she collapses. The surgeon then admits the patient to the ICU for cardiorespiratory arrest.

In this case, the surgeon performed an E/M service and then had to provide critical care after the patient collapsed. You would report the following:

- 99285 for the initial E/M

- 789.06 (Abdominal pain; epigastric) and 787.01 (Nausea with vomiting) linked to 99285

- 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care

- modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on 99291 to show that the critical care and E/M were separate.

- 31500 (Intubation, endotracheal, emergency procedure) for the intubation

- 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest]) for the CPR

- 427.5 (Cardiac arrest) and 410.9x (Myocardial infarction; unspecified site) as diagnoses linked to 99291, 31500 and 92950.

You should include a copy of the chart with this claim, Blakeman says, because some insurers will be reluctant to pay for 99291 and 99285. "Medicare, for example, will deny one of the services upon initial claim processing but will reverse the denial if you request a claim review and the chart supports the claim for both services," he says.

Best bet: Be prepared to appeal your claims that contain both critical care and E/M codes. You may not get fully compensated for these encounters the first time you file the claim, but extra effort on appeal should net you the rightful reimbursement.

More to come: Next month, part 2 of this article will tackle how to report procedures following an ED E/M service, how to report non-ED services in the emergency department, and more.