Neurosurgery Coding Alert

Question: An emergency department physician asked our surgeon to see a Medicare patient with head injury which the patient had while playing golf. The ED doctor specifically requested that our surgeon take responsibility for treating the patient, so it would not be appropriate to report this as consult. Is it correct to report ED codes when our neurosurgeon is not an ED physician?

New York Subscriber

Answer: Any physician can report the ED codes, 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: ..... Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are self limited or minor) -99285 (......Usually, the presenting problem[s] are of high severity and pose an immediate significant threat to life or physiologic function), if he provides a service in the ED. This does not mean, however, that you have an ED code as the only choice when your surgeon sees a patient in the ED.

According to the Medicare Carriers Manual section 15507, specialists should report an ED visit for services rendered in the ED, unless:

• the service provided meets the criteria for a consult
• the physician delivers critical care services, 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)-99292 (Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes [List separately in addition to code for primary service]) upon arriving at the ED, or the physician admits the patient to the hospital.

If your surgeon provides any of these three services, you should report the respective E/M service code instead of the ED visit. In addition, if the ED physician examined the patient before your physician entered the picture, there's a good chance that the ED physician will report an ED code. Most payers will only reimburse one code from this series per event. If the ED physician bills an ED code for the patient, you should report the appropriate E/M code such as 99201 (Office or other outpatient visit for the evaluation and management of a new patient... Typically, 10 minutes are spent face-to-face with the patient and/or family) – 99215 (Office or other outpatient visit for the evaluation and management of an established patient... Typically, 40 minutes are spent face-to-face with the patient and/or family).

In your case, the neurosurgeon clearly accepted full care for the patient, so a consult is not an option. You do not mention any critical care services, so you will not report 99291-99292, either.

If the surgeon subsequently admits the patient to the hospital, you submit codes 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components... Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit) – 99223 (...Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit). If your surgeon orders observation, you submit codes 99218 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components... Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit) – 99220 (...Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit). For a same-day admit and discharge, use 99234 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components... Typically, 40 minutes are spent at the bedside and on the patient's hospital floor or unit) – 99236 (...Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit).

Private payers may not follow these guidelines: Some non-Medicare guidelines may indeed insist that only ED physicians can use ED service codes 99281-99285, which can force you to report outpatient E/M or consult services in defiance of CPT^® and CMS rules to keep within the individual payer's guidelines. If your payer stipulates such rules, be sure to get its recommendations in writing and follow them to the letter.