Orthopedic Coding Alert

Because of the nature of orthopedic care, the hospital emergency department is a common setting in which the orthopedist sees patients. The CPT has a specific section for emergency department services (99281-99285), and at first glance, these codes appear to be the ones of choice for reporting orthopedic Evaluation and Management (E/M) services in the emergency department. But claims using these codes may be denied because many specialty doctors are using them incorrectly, accordingly to Doris Fullerton, CPC, president of the Fullerton Group, a medical management consulting firm. Just because you see a patient in the emergency room does not justify the use of the emergency department services codes, she adds. Here are examples of various situations in which an orthopedist might see a patient in the emergency department and correct coding advice for each.

1. ED New Patient Evaluation, Patient Admitted to Hospital.

An emergency department physician calls the orthopedist to see a patient who has a severe Colles fracture. After an examination in the ED, it is determined that the patient should be taken to surgery for a closed reduction. The patient is released later that day. In this case, the ED physician that first saw the patient will use the ED services codes (99281-99285), and the orthopedist should bill the correct level of outpatient consultation (99241-99245), appending modifier -57 (decision for major surgery), along witht he appropriate reduction code.

2. ED Consultation.

A patient presents in the emergency room with low back pain. The ED physician has seen the patient and is looking for a second opinion before sending him home with muscle relaxants, pain medication and bed rest, so he calls the orthopedist. The orthopedist goes to the ED and examines the patient. After the exam, the orthopedist delivers an oral opinion to the ED doctor, dictates his recommendation into the medical record and leaves the patient in the care of the ED physician. The orthopedist does not intend to treat the patient.

In this situation, the orthopedist would use the outpatient consultation codes (99241-99245 - office and other outpatient consultations, new or established patient), as per level of history, physical examination and medical decision-making required to render the second opinion. Its important to remember that consults are simply a request for an opinion. To qualify as a consult, the service and documentation must include the three Rs: a reason, request and reply. The medical record should reflect the name of the physician who requested the consultation, the reason for the consult, and what was reported in the reply.

Tip: A request for the performance of a specific procedure is not a consultation.

3. Providing a Service in the ED.

The husband of a patient calls their orthopedist after office hours because his wife has fallen at home and is having some significant pain in her knee. The orthopedist is already at the hospital and agrees to meet the patient and her husband in the emergency department. The patient does not see the ED physician prior to seeing the orthopedist.

In this situation, the orthopedist is clearly providing an emergency department service, and so the visit would be billed using ED services codes (99281-99285 - new or established patient), as per the level of history, examination and medical decision-making that was required to treat this patient. Also, adequate documentation in the patients medical record is essential.

4. Ordinary E/M Services in the ED.

While at a neighboring hospital, an orthopedist may see several established patients in their emergency department, since he doesnt have an office in that town.

In this situation, the orthopedist would use 99211-99215 (office and other outpatient service - established patient) if the presenting problems were not considered an emergency. This reflects the fact that the physician was treating established patients in the emergency department in the same manner as he would have at the office. The ED codes should be used only if the presenting problem requires immediate medical attention and can therefore be considered an emergency.