Part B Insider (Multispecialty) Coding Alert

Who Can Bill 99281-99285?

How can you cope with a situation in which one patient saw more than one physician in the emergency room? Especially if one of those physicians wasn't an ER doc, it can be confusing and vexing.
 
Part of the problem comes from a mistaken belief that only ER docs can bill for ER codes, experts say. It states clearly in the front of the Current Procedural Terminology book that any qualified physician can bill for any code in any setting, says David McKenzie, director of reimbursement with the American College of Emergency Physicians in Irving, Texas. The key word here
is "qualified."
 
It is possible for two different doctors to bill for evaluation and management services in the ER, says Steve Verno, director of reimbursement with Emergency Medicine Specialists in Hollywood, Fla. For example, if a patient sees an ER doc and then her own primary-care physician comes in to take over, both physicians can bill from the 99281-99285 series of ER E/M codes.
 
Most likely, the ER doc would bill a level two or lower, because her medical decision-making was low, whereas the primary-care doc would be a level three or four because he took over. Verno says these situations are rare, but he has seen two ER-specific E/M services billed for one patient on the same day.
 
But if an ER physician calls in an orthopedist or a neurosurgeon, for example, the non-ER doc should bill for a consultation, McKenzie says. "If all they're doing is an E/M, then more likely they're either going to admit the patient or they're going to do a procedure," McKenzie says. In either case, the specialist should bill for an admission or a procedure, not the E/M.
 
"Typically the rule is one E/M service per physician per patient per day," he says. It's difficult to bill for more than one E/M service for a single patient, even with different physicians, so he recommends billing for a consult if at all possible. But if the patient visits the ER twice in one day, the second visit isn't free - you'd either combine the visits or bill them separately using modifier  -59 (Distinct procedural service), McKenzie says.
 
If a patient comes in with a fracture and the ER doc passes him on to an orthopedist, both doctors can bill for a fracture code, Verno says. The ER doc should append modifier -54 (Surgical care only), and the orthopedist should append modifier -55 (Postoperative management only).