Primary Care Coding Alert

Like most coders, you probably assume that a family physician and an emergency physician cannot use emergency department (ED) services codes (99281-99285) for care of the same patient on the same day and both get paid by Medicare. But, if you take a closer look at the Medicare Carriers Manual (MCM), you'll be happy to discover you're wrong.

The MCM contains a very clear directive that many coders are unaware of. It specifically instructs carriers to advise physicians that they should use ED codes when they provide care to a patient in the ED but do not admit the patient to the hospital. Medicare says primary-care physicians (PCPs) should use the ED codes even when the ED physician also uses those codes.

FPcoders who follow this instruction say Medicare does reimburse them. Barbara Holley, CPC, CCSP, a coding specialist at the Stuart, Fla.-based Martin Memorial Medical Group, says she is not aware of any denials by Medicare during the more than two years her office has coded ED visits according to this directive. Offices that have been denied when using ED codes properly for FPservices should copy the appropriate section of the MCM and send it to the carrier with their claims.

The relevant part of MCM, Section 15507, says, "Any physician seeing a patient registered in the emergency department may use these codes." Section F-2 specifically addresses how to code when a patient's personal physician sees the patient in addition to the ED physician but does not admit the patient:

Although Medicare says an ED code not an outpatient E/M code should be used when the FPsees a patient in the emergency department, some private carriers may balk at paying an ED code for both an FPand the ED physician. "FPs should know they can bill the ED codes even if the ED physician has already seen the patient; understand, however, this applies to Medicare rules only," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "Commercial carriers are much more stringent in their interpretations and often do not allow the same flexibility in coding ED visits."

In those cases, some coders advise using the appropriate outpatient E/M codes (99201-99215) instead of the ED codes for the FP's treatment of a patient who is seen in the ED but not admitted to the hospital.

However, coders who have been successful in using the ED codes recommend trying the ED codes again with private payers if you have not done so in six months. In addition to Medicare's directive on this issue, the CPT manual advises coders to use ED codes when services are provided in the ED. In the opening section for "office or other outpatient services" in the Evaluation and Management section, the CPT manual states: "For services provided by physicians in the emergency department, see 99281-99285."

FPs who follow Medicare's directive regarding ED codes can expect slightly higher reimbursement if they typically have used the outpatient E/M codes for care of ED patients who are not admitted. For example, for relatively equal examination, history and medical decision-making levels in Florida, ED code 99283 will pay $61.94 compared to $35.04 for outpatient E/M code 99213. However, a consultation carries the highest reimbursement, with 99242 paying $71.05. Figures in other areas will vary slightly from these amounts.

Note: The reimbursements for outpatient E/M and consultation codes above may appear less than the normal amounts for those codes. That is because the physician must take a site-of-service reduction when using the outpatient E/M (99201-99215) and consultation (99241-99245) codes in the ED. Because the services are not performed in the office, the practice-expense portion of the total relative value unit (RVU) is less. The figures above reflect this reduction.