General Surgery Coding Alert

You already know that your surgeon can report 99281-99285 if she attends to a patient in the emergency department (ED) -- although you may be better off choosing a consultation or inpatient admission code, depending on the circumstances. What you may not know is how to report ED E/M services when combined with a same-day procedure or another, same-day E/M service.

Read on for four more tips -- in addition to those you learned in Part 1 of this series, "Revive Your ED E/M Coding, STAT," in General Surgery Coding Alert, Vol. 10, No. 2 -- to complete your knowledge of how to handle your ED coding claims.

If your physician provides an ED service and, based on that service, then performs a minor procedure (a procedure with a zero- or 10-day global period) on the same date of service, you-ll want to append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the ED code. This tells the payer that the ED service was separate and significantly above the procedure's "inherent" E/M component, says Kate Kibat, CPC, compliance educator at the University of Washington Physicians in Seattle.

The documentation should reflect that the physician workup includes more than just the problem-focused service that is typically part of a procedure, and that as a result of the E/M, the physician determined to perform the procedure. The payer has to be able to see from the chart that the E/M is not the minor E/M (history, exam and medical decision-making) built into all medical procedures.

Example: A patient with a long laceration on the left forearm presents to the ED. The physician performs an E/M service and documents a history, exam and MDM to evaluate the patient, determine if there are other injuries and decide on the best course of treatment. He then performs a simple repair of the wound (for example, 12006, Simple repair of superficial wounds of scalp, neck axillae, external genitalia, trunk and/or extremities [including hands and feet]; 20.1 to 30.0 cm).

In this case, you would report 12006 for the wound repair, plus the appropriate-level E/M service (such as 99282). You should append modifier 25 to the E/M service to differentiate the service as significant and separately identifiable, Kibat says.

When the physician provides an ED service and, based on that service, performs a major surgical procedure (any procedure with a 90-day global period) on the same or the next date of service, you should append modifier 57 (Decision for surgery) to the ED E/M code. This tells the payer that the surgery was not scheduled or planned and that the surgeon has not already been paid for the pre-operative component of the global surgical package, says Barbara J. Cobuzzi, MBA, CPC, OTO, CPC-H, CPC-P, CHCC, consulting editor of publications for the American Academy of Professional Coders, the coding organization in Salt Lake City.

Example: A patient with right lower quadrant abdominal pain presents to the ED. Upon examination, the surgeon suspects the patient has appendicitis and schedules an immediate appendectomy.

In this case, you should report the appendectomy (44950) along with the ED service level best supported by the physician's documentation. Because 44950 has a 90-day global period, you should append modifier 57 to the ED service code to alert the payer that the ED visit was when the physician arrived at the decision to perform surgery, no prior presurgical visits have been paid, and therefore that visit is not bundled with the surgery itself and is separately payable.

If the physician sees the same patient twice on the same date of service (either in the ED or in the ED and another site of service), you might be able to report two E/M services but probably only in the rare case that the chief complaint at each visit is entirely different, Kibat says.

Quick example: If a patient with abdominal pain presented to the ED in the morning, received treatment, and returned in the evening with a sprained ankle, you might be able report two separate encounters. Be aware that the physician's documentation will have to prove definitively that the two E/M services were not related.

Tip: If the repeat visit somehow results as a consequence of a perceived lapse in medical care or evaluation, or a callback -- for example, a change in radiologic interpretation -- don-t bill for the second visit.

Handling ED Location for a non-ED patient

On occasion, a surgeon may ask a patient to meet him in the ED for the physician's convenience, such as when the surgeon is already at the hospital

In these cases, the patient does not register into the ED, and the surgeon is really using the ED as an outpatient facility. Because the patient is not an ED patient, you should report an established outpatient visit (99212-99215), as documented and supported by medical necessity.

Final tip: Remember, in this case, the place of service is outpatient hospital (POS 22), not office (POS 11).

In the vast majority of cases, if the physician sees the same patient for two E/M services on the same date of service, you-ll combine the visits into a single E/M, Cobuzzi says. A notable possible exception involves critical care services, as outlined in Part 1 of this series.

Example: A patient who is on Coumadin presents to the ED with epistaxis. The doctor performs the appropriate history and examination and packs the patient's nose. The bleeding stops and the surgeon discharges the patient.

Later that day, the patient returns with increased bleeding. Again, the surgeon performs the relevant history, exam and lab work. He then repacks the patient's nose and gives her vitamin K.

In this case -- because the visits were related -- you should combine the two encounters into a single E/M service. Although each encounter judged separately might warrant a level-one or -two service (99281 or 99282), when combined the services could support reporting a level-three service (99283), for instance.

Beware Modifier 27

Don't think you can apply modifier 27 (Multiple outpatient hospital E/M encounters on the same date) to gain reimbursement for two related (or unrelated) E/M services on the same day. Modifier 27 does not apply to professional services, only to facility billing.

Even if your surgeon is employed by the hospital, modifier 27 still isn't appropriate. The employment arrangement should never affect billing for physician services, with the exception of the tax identification number that goes on the claim form.

You should never report 99281-99285 on the same date of service as:

- Comprehensive Nursing Facility Care (99304-99306): "Payment for evaluation and management services on the same date provided in sites other than the nursing facility are included in the payment for initial nursing facility care when performed on the same date as the nursing facility admission," according to Medicare's Internet Only Manual (Publication 100-4, Chapter 12, Section 30.3.11D).

- Hospital Admission: When the surgeon admits the patient to the hospital with initial hospital care 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 ...), you should report only the admission code.

- Observation Care: If the surgeon 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 any of the above cases, however, you may consider the surgeon's documentation during the ED visit when deciding on an appropriate E/M service level for the "definitive" service (such as the inpatient admission) that the surgeon provides on the same date.

Example: The surgeon sees an accident victim in the ED and records a detailed history and exam and MDM of high complexity. The surgeon subsequently decides to admit the patient to the hospital.

In this case, the surgeon will not have to provide a "separate" history, exam and MDM to meet the requirements of the hospital admission service. Instead, he may count the history, exam and MDM he performed in the ED toward the admission (for example, 99221, Initial hospital care, per day, for the evaluation and management of a patient -).