Reimbursement Advisor

Gravidas in the ER


Q It is our understanding that if a gravida is in the emergency room (ER) triage for less than 6 hours, we should bill an office visit/out-patient facility E/M code. Why not report an ER E/M visit unless the patient is admitted to observation status?

A Multiple problems arise when using the ER E/M codes (99281 to 99285), making the office visit/outpatient facility E/M codes a better alternative (99201 to 99215).

First, a payer may require that you prove it was an emergency, thereby slowing payment. Second, to report an ER code, you must document all 3 of the key components (history, exam, and medical decision-making), and you cannot use time as a default if any counseling or coordination of care took place. Third, the service must have been rendered in the ER; labor and delivery (L&D) does not qualify as an emergency department, even though that may be where all pregnant patients are sent. Fourth, the ER codes usually do not pay that well, especially since the physician may have only performed a problem-focused exam on the patient. This means that only a level 1 service can be billed because the lowest level of any of the 3 key components determines the level of service.

For these reasons, many physicians have decided simply to bill for the outpatient E/M service, and if the time with the patient was prolonged due to her condition, they bill for the additional time using the CPT “prolonged services” codes, provided that the time spent and medical necessity for the service have been documented in the patient’s medical record.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Next Article: