Pathology/Lab Coding Alert

Question: An emergency department (ED) physician asked our hematologist/pathologist to treat a patient in the ER for a blood transfusion reaction. This isn’t a consult because our physician took responsibility for patient care. Can we report the ED codes for our pathologist/hematologist even though he is not an ED physician?

Louisiana Subscriber

Answer: A common misconception is that only emergency department (ED) physicians can report emergency room services (99281-99285, Emergency department visit for the E/M of a patient...). In fact, any physician can report the ED codes if he provides a service in the ER. 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, primary-care physicians and 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 (99221-99223, Initial hospital care, per day, for the E/M of a patient ...; 99218-99220, Initial observation care, per day, for the E/M of a patient ...; 99234-99236, Observation or inpatient hospital care, for the E/M of a patient including admission and discharge on the same date ...).

If your pathologist/hematologist provided any of these three services, you should report the respective E/M service code instead of the ED visit.

In your case, the pathologist/hematologist 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 doctor subsequently admits the patient to the hospital (99221-99223) or orders observation (99218-99220) on the same date of service, you should report that service instead of the ED visit codes. For a same-day observation order and discharge, use 99234-99236.

As you describe your case, and because the ED physician transfers care to your pathologist/hematologist, you could report an ED visit, such as 99282.

Private payers may not play ball: 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 and receive payment for services rendered. Or, they may stipulate that only one ED service can be reported per date of service and if the ED physician is billing for seeing the patient, your physician may not be allowed to do so. If your payer stipulates such rules, be sure to get its recommendations in writing and follow them to the letter.