Primary Care Coding Alert

Confusion over when to bill for a consultation and when to bill emergency department (ED) services can stop now. The key factor is the intent behind the ED physician's request to the FP.

"Is the ED physician asking for an opinion?" asks Jean Ryan-Niemackl, LPN, CPC, compliance analyst for MeritCare Health Systems, a multispecialty system in Fargo, N.D. Or is the ED physician asking the other physician to take over care of the patient?

If the ED physician is asking the FPto assume care of the patient and the patient is not admitted to the hospital, use the ED codes.

For example, an elderly patient with a history of heart disease calls her FPand complains of indigestion and abdominal pain. The FPdirects her to the ED. The ED physician examines the patient, is not sure whether she should be admitted, and asks the FPto come to the ED to evaluate her. After arriving, the FPtakes a history, examines the patient and decides not to admit, instead advising the patient to come to the office the next day for tests and blood work.

The ED physician codes the appropriate ED code based on his or her level of involvement in the case, and the FP does the same. Both diagnosis codes can be the same.The ED codes are properly used here because the FPsaw the patient in the ED and assumed care of the patient rather than simply rendering advice to the ED physician.

When selecting an ED code in this scenario, FPs should be aware that time cannot be used as a factor for code selection because there are no typical times for ED codes in CPT and all three key components required for the code must be met. This is different from the criteria for an established patient E/M visit (99212-99215), where a code can be used if two of the three key components are met and time can be a factor under some circumstances.

For example, to code a midlevel ED visit of 99283, the physician must complete an expanded problem-focused history, perform an expanded problem-focused examination, and use medical decision-making of moderate complexity. If the physician's visit meets the first two criteria but includes medical decision-making of low complexity, 99282 should be billed instead of a 99283.

Ryan-Niemackl says it is critical that the physician document all three components in the chart fully or proper reimbursement may not be given. For reimbursement, the physician needs to remember that it "doesn't matter what they do; it matters what they document," she says. In other words, payers will consider only what the physician documents in the record in determining the proper payment.

In addition, FPs should note that they cannot bill any charges if they simply talk with the ED physician on the phone rather than coming on-site.

"That is key," says Barbara Holley, CPC, CCSP, a coding specialist at the Stuart, Fla.-based Martin Memorial Medical Group. "The primary-care physician has to actually come in to the ED. He can't bill unless there is a face-to-face encounter."

The FP may use one of the consultation codes (99241-99245) for a visit to the ED to see a patient at the request of the ED physician. If the ED physician is seeking an opinion only, the FP would use a consultation code, Ryan-Niemackl says.

For example, a patient with diabetes comes to the ED with high blood-sugar levels and disorientation. The ED physician calls in the FP to evaluate the patient. To qualify as a consultation, the FP's visit to the ED must meet certain criteria, including what are often referred to as the three R's: The ED physician needs to request the FP's advice, the reason needs to be stated, and a report from the FP needs to be completed. All three R's should be documented in the patient's ED record.

The FPmust also recommend treatment to the ED physician rather than provide it to the patient. For example, in the diabetic example above, the FPmight recommend that the ED physician change insulin levels and advise the patient, who has been drinking, to stop using alcohol due to its effect on blood-sugar levels.

However, if the FPassumes care of the patient and makes those recommendations directly to the patient before sending the patient home, the consultation codes would not be used. Instead, an ED code would be used.

Section G of the Medicare Carriers Manual outlines the proper procedure when the ED physician requests that another physician see the patient in the ED or other office/outpatient setting:

If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation (see 15506A) are met. If the criteria for a consultation are not met and the patient is discharged from the Emergency Department or admitted to the hospital by another physician, the physician contacted by the Emergency Department physician should bill an emergency department visit ... If the consulted physician admits the patient to the hospital and the criteria for a consultation are not met, he or she should bill an initial hospital care code.