General Surgery Coding Alert

Nugget: Two main factors determine how emergency department services are paid when the surgeon saw the patient and where the patient ended up.

National Medicare guidelines state that evaluation and management (E/M) services a surgeon provides to a patient in the emergency department (ED) should be billed using emergency department codes (99281-99285), unless these services qualify as a consult, critical care service or admission.

Revised guidelines in section 15507 of the Medicare Carriers Manual (MCM) clearly state that non-ED physicians, including surgeons, should bill such services using ED codes even if the emergency physician who initially saw the patient also bills using the same codes. Many carriers (local Medicare and private payers), however, do not follow Medicares lead on this issue, and will pay only one ED code per day regardless of the number of physicians who saw the patient.

There are at least seven different ways to bill an emergency department encounter, depending on the status of the patient:

1. ED visit

2. Consultation

3. Admission

4. Admit to observation

5. Critical care

6. Established patient visit

7. New patient visit

These choices make it difficult to correctly code the ED services provided by the surgeon. Medical billing decision-making has become more difficult than actual medical decision-making, says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C. Some surgeons just give up and decide not to bill for encounters rather than face the complex paperwork.

For coders, much of the confusion arises because some surgeons dont document where the patient ended up on a particular calendar date, says Arlene Morrow, CPC, a general surgery coding and reimbursement specialist in Tampa, Fla. For example, if the physician sees the patient in the emergency department and then discharges the patient, I use an ED code. On the other hand, if the patient is admitted and taken straight to surgery, I use an initial hospital visit code.

Note: The calendar date is important because if the patient arrives in the ED at 11 p.m. but is admitted to observation after midnight, two separate E/M services can be billed: the appropriate emergency department code (for the time before midnight) and an observation code (for the next day).

There are two main factors in determining how surgeons code encounters in the ED, Morrow says. The first is: When did the surgeon actually see the patient? The second is: Where did the patient end up?

To answer these two questions and bill the service appropriately, coders depend on the surgeons documentation of the encounter. Instead, what they often get is a short note that says ED consult or met patient in ED without other documentation to support a consultation. To avoid claim denials, surgeons need to provide this information to their coders, Morrow says.

Even if the carrier follows the relatively straightforward guidelines in the MCM, billing a service provided in the ED can be complicated. Depending on the calendar date and the location the patient ends up in, an ED visit code may be inappropriate or result in lower reimbursement, even though the service took place in the ED.

Consultations in the ED

Possibly, the biggest area of confusion when non-ED specialists bill for ED services is consults. According to the MCM: If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are met.

The criteria, which also changed as a result of revision 1644, are stated as follows in the MCM, section 15506:

1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by [the ED] physician.

2. A request for a consultation from [the ED physician] and the need for consultation must be documented in the patients medical record.

3. After the consultation, the consulting surgeon prepares a written report of findings that is provided to the [ED doctor].

In the hospital setting, a separate report is not required. The report can be an entry in the patients common medical records (i.e., progress notes, recommendations for treatment, etc.). Section 15506 states: In an emergency department or inpatient or outpatient setting in which the medical record is shared between the referring physician and consultant, the request for consult may be documented as part of a plan written in the requesting physicians progress note, an order in the medical record or a specific written request for the consultation. In these settings, the written report required for consult may consist of an appropriate entry in the common medical record.

If the consultation criteria listed above are not met and the patient is either discharged from the ED or admitted to the hospital by another physician, the surgeon contacted by the emergency department physician should bill an ED visit, not a consult. If the consultation criteria arent met and the surgeon admits the patient, an initial hospital care code should be billed.

Although many surgeons believe that because they are on call they are by definition performing a consult and routinely bill visits to the ED as such, this often is incorrect. This error particularly relates to Medicare, which states that consults should not be billed if a transfer of care has occurred. Due to the nature of the emergency department physicians job, transfers of care often occur; in those instances, a consult cannot be billed.

In addition, the service can be called a consult only if the ED physician asks the surgeon for advice on how to treat the patient, says Kathy Pride, CPC, CCS-P, a coding and reimbursement specialist at Martin Memorial Hospital in Port St. Lucie, Fla. And even then, if the ED physician already has done a workup on the patient, the surgeon may not be able to bill for a consult, Morrow adds.

For a consult to be billed, the surgeon would have to document the multiple differential diagnoses and treatment options and/or diagnostic workup under consideration, Morrow says. In other words, if the ED physician already has done a workup on the patient, the surgeon may not be able to bill for a consult.

Giving Established Patient Consults

A consult also may not be charged if the surgeon sends his or her own patient to the ED and later is asked for advice by the ED physician. If, based on the opinion of the surgeon, the patient is sent home, both the ED physician and the patients surgeon should bill the appropriate level of ED service, according to the MCM. The surgeon does not bill for a consultation because he or she is not providing information to the ED physician for use in treating the patient, even though the ED physician asked for the surgeons opinion.

In some shared-record situations, the surgeon may be able to bill for a consult if the patient is admitted to the hospital by a second specialist also called in at the ED physicians request, Morrow says. For example, a surgeon is called in to see a trauma patient who has closed head injuries as well as massive multiple injuries. The ED physician calls a neurosurgeon to assess the head wounds, and a general surgeon to evaluate other injuries (e.g., rule out a ruptured spleen).

The neurosurgeon admits the patient to the hospital for the head injury. Meanwhile, because the general surgeon was asked for and provided an opinion on the nature of the patients injuries and because only one hospital admission code (99221-99223) per patient per day is permitted, a consult can be charged, assuming the documentation provided meets the consult criteria outlined above.

Note: If the patients personal physician does not come to the hospital to see the patient but only advises the emergency department physician by telephone, then the patients personal physician may not bill anything at all.

Second Physician Can Also Bill ED Services

In August 1999, MCM revision no. 1644 changed the guidelines in section 15507 for ED services and instructed physicians to use ED codes even if an ED physician also bills for the same service. Some local Medicare carriers, such as First Choice in Florida, clarified their policies to conform to the new wording in the MCM.

The MCM guidelines in section 15507 now state:

These codes should be paid regardless of whether the physician is assigned to the emergency department.

Any physician seeing a patient registered in the emergency department may use these codes.

ED codes should be used only if the patient is seen in the emergency department.

ED codes should be paid regardless of whether the services were emergency services, as long as the patient was seen in the ED. A lower-level ED code should be reported for a non-emergency condition.

Before the new policy was announced, the problem was how to bill if a patient came to the ED, saw a surgeon and wasnt admitted to the hospital, says Pride. We never had a clear directive from our local carrier, so we relied mostly on word of mouth, basically, about how to do it. Some consultants said it was OK to charge for a consult. Then, when consults came under scrutiny, we were told to use office or other outpatient codes (99201-99215), with the ED as the place of service.

Under the new guidelines, surgeons who see patients in the ED can bill for any E/M services performed there using emergency department E/M codes, unless:

1. The patient is admitted to the hospital or to observation on the same calendar date, in which case initial hospital care or admit to observation codes should be used;

2. The encounter meets the criteria for a consult or for critical care services; or

3. The patient is not registered at the ED, even though he or she met the surgeon there; in such cases, an outpatient visit code (99201-99215) should be reported, with 23 (for ED) listed as the place of service.

Note: This will likely be subject to a site of service differential, whereby the carrier lowers the fee to reflect the fact that the physicians office costs arent taken into account because the service was provided elsewhere.

Until MCM guidelines were revised, most private payers and many local Medicare carriers accepted only one ED claim per patient per day. So if an ED physician saw a patient and then asked a surgeon to take over care of the patient, the surgeon had two options: If the patient was admitted, an initial hospital visit code (99221-99223) was billed; if the patient remained in the ED, the surgeon would bill the encounter as a new or established patient outpatient visit (99201-99215).

A new or established patient outpatient code also may still be required by some payers, including some local Medicare carriers that still look askance at concurrent ED billing by an ED physician and a surgeon or other specialist. Billing such claims with an ED code often will result in the surgeons claim being denied; although appealing such denials may be successful, doing so again and again can be time-consuming. So coding experts recommend getting the carriers policy on MCM section 15507 (preferably in writing) before billing ED E/M codes.

If the carrier will not recognize two ED codes on the same day for the same patient, an outpatient code should be used with the ED listed as the place of service on the HCFA 1500 claim form.

Note: If local Medicare carriers deny the surgeons ED E/M claim, the Medicare Carriers Manual section 15507 should accompany any appeal.

Coding Critical Care in the ED

Patients may require critical care, defined by CPT as medical care of a patient with a critical illness or injury that acutely impairs one or more vital organ systems, such that the patients survival is jeopardized, when he arrives at the emergency department.

The codes for critical care services 99291 and 99292 are time-based and require a minimum of 30 minutes for billing. They also may be billed only by one physician per patient per time period. These restrictions mean that the care the surgeon provides at different times may be similar, but depending on the circumstances, either a critical care code or a level-five emergency department E/M code may be billed.

Note: Because emergency department service codes arent time-based they cannot be prolonged. As such, prolonged service codes cannot be claimed in addition to ED codes, whereas they can be claimed with critical care codes if the times are documented and other requirements are met.

ED codes should not be reported on the same day critical care services are billed. According to section 15508 (Rev. 1644) of the Medicare Carriers Manual, If critical care is required upon the patients presentation to the emergency department, only critical care codes 99291 or 99292 may be reported. Emergency department codes will not be paid for the same day.

Regardless of the patients condition or the service provided, unless the surgeon spends at least 30 minutes with the patient and the documentation supports the criteria for critical care, this service cannot be billed and (presumably) a level-five emergency services E/M code should be used instead.

The clinical criteria for using a level-five emergency code are not that different from those used for critical care. According to the CPT manual, for a level-five emergency department visit, usually, the presenting problem[s] are of high severity and pose an immediate threat to life or physiologic function.

If two physicians work on a critical patient and both satisfy the critical care criteria, only one may bill using a critical care code per time period. The primary surgeon who worked on the most difficult problem would bill for critical care; the other surgeon would use a level-five emergency code.

Note: CPT code 92950 (cardiopulmonary resuscitation [e.g., in cardiac arrest]) may also be appropriate in some situations.

Choosing the Right Admit or Observation Code

If the surgeon sees the patient in the ED and then admits the patient to the hospital on the same calendar date, only an admission code (99221-99223) can be billed, according to the MCM. All E/M services provided by the surgeon are considered part of the initial hospital care when performed on the same date as the admission. If, however, the surgeon sees the patient in the ED on day one and admits the patient on day two (defined as beginning at midnight), even if fewer than 24 hours has elapsed, an ED visit may be billed for day one and an admission billed for day two.

The same rules apply for admitting a patient to observation. The place of service, however, must be specified and must agree with the hospitals own documentation regarding the patient.

Note: For more information on observation E/M services, see General Surgery Coding Alert, Observation Codes Used Correctly Can Pay Off,#Vol. 1, No. 2, August 1999.

For example, a patient is admitted to observation for 24 hours after a car accident because there is fluctuation in the patients vital signs. Even though the patient is seen in the ED, the surgeon should bill an admit-to-observation code (99218-99220, initial observation care, per day), as long as the surgeon notes the place of service (section 24b on the HCFA 1500 claim form) as 22 to designate outpatient/hospital status. The hospitals own claim for the encounter, however, must also indicate that the patient was placed in observation. Otherwise the claim may be denied.

Some coders and physicians may confuse observation and inpatient status, particularly if the patient first arrives in the ED, which is its own place of service (23). In addition, Morrow says, many surgeons are unaware that there are newer observation codes (99234-99236) that should be used when a patient is admitted (either to the hospital or observation) and then discharged on the same day.

Its important that physicians document the calendar days they saw the patient on, Morrow says. If the surgeon sees the patient on the ED floor in the morning and then admits the patient in the evening, everything that transpired on that calendar day is included in the higher level of service (i.e., the admission).

Finally, if the surgeon performed a level-five ED service and admitted the patient the next day with minimal history and physical, only a level-one (99221) initial hospital care code should be used for the admission, according to the MCM revised guidelines. As is always good practice, coders should contact their carriers to determine the best way to bill in these situations.