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 [...]