Primary Care Coding Alert

Question: How can our FP get paid for an emergency department visit when he is called to the ED to determine if the patient should be admitted or sent home? Medicare denied our doctor's visit, saying it was not medically necessary and that both the FP and the ED physician used the same diagnosis codes.

Missouri Subscriber

Answer: If both physicians are using the same diagnosis code(s), one way to establish the medical necessity of the FP's service is to use a different kind of CPT code than the emergency physician uses. In your example, the emergency physician would likely use an ED code (99281-99285) for his service. The FP could use an outpatient consultation code (99241-99245) because the emergency physician requested his opinion about whether the patient should be admitted or sent home.

Of course, the Medicare carrier may still deny the services on the basis of medical necessity in essence, questioning why the emergency physician was not capable of deciding to admit or discharge on his own. If medical necessity cannot be established through proper CPT and ICD-9 coding, you can appeal the denial and hope that medical necessity can be established through a review of the chart notes. Consider consulting Medicare policy on concurrent care, as this may be the basis for denial of medical necessity.

You can find information on Medicare's concurrent care policy in the Medicare Carriers Manual at section 2020.E (available online at http://www.hcfa.gov/pubforms/14%5Fcar/3b2000.htm). Also, see the July 2002 issue of Family Practice Coding Alert for the article "Diagnosis Directs Payment for Concurrent Care Coding."