Reimbursement Advisor

3 elements are required for an emergency code

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Q If I saw my patient in the Emergency Department (ED), can I bill one of the 99281–99285 codes for ED visits? Or are these codes only for providers who work for that hospital’s ED?

A No, these codes do not apply exclusively to services provided by the hospital’s ED employees.

You may use ED codes if you are the only one who provided services in that setting. But remember, the codes for ED services require that all 3 key components—history, examination, and medical decision-making—be documented. The “typical times” that are part of most E/M service definitions have not been established for these codes, so selecting the level based on counseling and/or coordination of care is not an option.

Lower relative values

Also keep in mind that the relative values assigned to lower level ED codes 99281 (ED visit; problem-focused history and exam with straightforward medical decision-making) and 99282 (ED visit; expanded problem-focused history and exam with low complexity of medical decision-making) are lower than their equivalent outpatient codes (99201, 99202, 99212, or 99213).

If the ED physician saw the patient first and is billing for that service, you need to bill the outpatient evaluation and management codes (99201–99215) or an outpatient consultation (9941–99245) if you documented a consultation in the record and if the patient is not being seen in the ED for a condition you are actively treating in your office setting.

This assumes you did not admit the patient to either observation status or as an inpatient. In that case, CPT rules would let you bill only the admission, but the code level selected would be based on all services you provided to that patient, on that day.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects 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.

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