Medicare Compliance & Reimbursement

Question: A mother called and reported her baby was having trouble breathing. A nurse recognized that the problem required emergent status and advised her to come in immediately. When the mother arrived, a nurse performed triage assessment. She determined the patient’s breathing was no longer an emergency clinical condition and scheduled an appointment for the baby in an open time slot two hours later. Can I use 99058 for the walk-in?

Answer: No. If, during triage assessment, a nurse determines a patient’s clinical condition is not emergent and works the child into an open time slot, you should not use the emergency service code (99058, Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service).

Proper protocol: Use 99058 only when the patient requires immediate physician attention, which interrupts her scheduled appointments.

Example: A mother walks into your office with a three year old who has an active nosebleed that requires emergency management. The pediatrician manages to stop the bleeding with ice. She reports the epistaxis control by conventional methods with the appropriate level E/M service (99201-99215, Office or other outpatient visit …) and 784.7 (Epistaxis; hemorrhage from nose, nosebleed). You denote the service required the physician to interrupt her schedule with 99058.