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 dont think this can count as a consult. 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 Claims Processing Manual, specialists should report an ED visit for services rendered in the ED, unless the:

" service provided meets the criteria for a consult

" physician delivers critical care services (99291-99292) upon arriving at the ED, or

" 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.

Watch out: If the ED physician examined the patient before your physician entered the picture, theres a good chance that the ED physician will report an ED code.Most payers will reimburse only 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.

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 stipulate 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 payers guidelines. If your payer stipulates such rules, be sure to get its recommendations in writing and follow them to the letter.