Orthopedic Coding Alert

Question: An emergency department physician asked our surgeon to see a Medicare patient with severe shoulder pain following a golf injury. The ED doctor specifically requested that our surgeon take responsibility for treating the patient, so I don’t think this can count as a consult. But can I report an ED visit for our surgeon, who is not an ED physician?

New York Subscriber

Answer: Contrary to popular belief, any physician can report the ED codes (99281-99285, Emergency department visit for the E/M of a patient…) if he provides a service in the ED. This does not mean, however, that an ED code is the only choice when a physician 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 (99291-99292) 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 99201-99215.

In your case, the orthopedic surgeon clearly accepted full care for the patient, so a consult is not an option. You don't mention any critical care services, so you wouldn't report 99291-99292, either. 

If the surgeon subsequently admits the patient to the hospital (99221-99223) or orders observation (99218-99220), you should report that service. For a same-day admit and discharge, use 99234-99236. 

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.