Orthopedic Coding Alert

Question: Can we use the 99211-99215 series of codes for ER visits? My insurer denies them, saying that the ER is not an acceptable place of service for this code series. I believe that when the orthopedist is called into the ER to assume care of a patient, we should bill using the 99211-99215 series rather than using a consult code. After all, the ER is considered outpatient.

Indiana Subscriber

Answer: Although the emergency department E/M codes (99281-99285) are not limited to the emergency department (ED) physician, that's usually the most likely person to bill that code series, and no insurer will pay both the ED physician and the orthopedist for these codes on the same day. You are correct in reporting an office or other outpatient visit code (99211-99215) when an established patient calls the orthopedist, who tells the patient to meet him in the ER.

Some insurers may say that the outpatient office visit codes should be used for office visits only, but that's a misinterpretation on their part and a disregard for CPT guidelines. Payers see the place of service listed as an emergency room and immediately deny the claim, but you need to fight those denials. Write a letter to the insurer appealing the rejection, and indicate what the patient's condition was and why he required the doctor's specialty care in the ER.

Don't assume, however, that you cannot report an outpatient consultation code when the ED physician calls your orthopedist to evaluate a patient. Each encounter must be evaluated individually.