Primary Care Coding Alert

Family physicians (FPs) are often called when a patient is seen in the emergency department (ED). These visits can trigger a variety of coding scenarios, depending on the roles the ED physician and FP play in the patients care and whether the patient is subsequently admitted to the hospital. Among the codes that may be assigned include emergency department services codes (99281-99285), outpatient service codes (99201-99215), and initial hospital care codes (99221-99223).

Family practice coders say there are six ED scenarios they struggle with most frequently.

1. The patient is seen in the ED, but not admitted as an inpatient.
For example, a 68-year-old male is seen in the ED complaining of shortness of breath. The patient, a smoker, had recently been treated by the family physician for a respiratory infection. The ED physician asks the FP to examine the patient. The FP sees the patient in the ED, prescribes an antibiotic, and sends the patient home with instructions to make an office appointment the following week.

The FP, like the ED doctor, would report an ED service code, according to Kathy Pride, CPC, CCS-P, coding specialist for Martin Memorial Medical Group, a practice with 57 primary care physicians in Stuart, Fla. In this instance, either 99282 (emergency department visit for the evaluation and management of a patient, which requires an expanded problem focused history and examination, and medical decision making of low complexity) or 99283 (emergency department visit for the evaluation and management of a patient, which requires an expanded problem focused history and examination, and medical decision making of moderate complexity) is assigned. ED codes follow standard evaluation and management (E/M) documentation guidelines, and do not distinguish between new or established patients.

Pride notes that many family practice coders are reluctant to use ED services codes, believing only physicians assigned to the ED can report them. However, any physician seeing a patient registered in the ED may report these codes.

Additionally, she says, some private payers may pay only one physician for the same episode of care using ED codes, challenging the medical necessity of two physicians providing concurrent care. In this situation, some coding professionals recommend reporting outpatient visit codes although others note that the introductory text for outpatient codes explicitly states, For services provided by physician in the emergency department, see 99281-99285.

2. Family physician provides consultation to the ED physician.
Pride explains that consultation codes (99241-99245) may also be used in limited circumstances when the FP provides an opinion to the ED physician but the patient is not admitted to the hospital. This coding scenario must be approached carefully, however, because strict criteria govern use of consultation codes. It is to the family physicians advantage to [...]