Medicare Compliance & Reimbursement

Myth: Only a certified emergency department (ED) physician can report 99281-99285.

Reality: Any physician can report these codes for ED services, as long as the visit meets the ED code criteria. But keep in mind 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, keep three points in mind:

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."

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

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 ED services call for an ED code. You should not limit your choices to 99281-99285 for services your physician 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) 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; 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 a 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 ...), says Jaime Darling, CPC, coder with EA Health Corporation in Solana Beach, CA. 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.

The consulting physician should report the consult code, and "the ED physician can still bill an ED code (99281-99285) for his or her portion," Darling says.

Caveat: If the consulting physician's documentation did not meet the consultation guidelines, CMS says you should instead report an ED code for the surgeon's evaluation, Darling says.

"That would mean two ED codes get billed on the same day. Since they are coming in from different physicians (most likely with different diagnoses, too), they should both be paid," she says.