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General Surgery Coding Alert

Part 1:

Revive Your ED E/M Coding, STAT

You can report an ED visit and critical care, with modifier 25 Many coders are unaware that, under CMS and CPT rules, any physician can report 99281-99285 for emergency department (ED) services. Just as important, however, you must know that the ED service codes are not your only choice in these situations. Depending on the circumstances and the strength of the available documentation, you may be better off to claim a consultation, admission service, or even critical care. 3 Tips for Applying ED Codes When reporting ED services (99281-99285, Emergency department visit for the E/M of a patient -), keep three key points in mind: 1. You may report 99281-99285 only for physician services provided in the ED. An ED, as defined by the Medicare Internet Only Manual (IOM, Publication 100-4, Chapter 12, Section 30.6.11B), is "an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention." CPT defines an ED similarly as "an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention." You should not report 99281-99285 for services (even "emergency" services) the physician provides in the office or outpatient setting other than an ED. 2. You can report 99281-99285 even for non-emergency services provided in the ED. "The only requirement for using the emergency department codes is that the patient be seen in the emergency department for an unanticipated service," the IOM states. 3. Any physician -- not only those assigned to the ED -- can report 99281-99285. Medicare's IOM specifically states, "Any physician seeing a patient in the ED may use ED visit codes for services matching the code description. It is not required that the physician be assigned to the emergency department to use ED visit codes." Not all private payers follow the same rules: Some non-Medicare payers may insist (in defiance of CMS and CPT guidelines) that only ED physicians can use 99281-99285. If this is the case, be sure to get the payer's recommendations in writing, and follow them to the letter. Not All ED Services Call for an ED Code You should not limit your choices to 99281-99285 for services your surgeon delivers in the ED. For instance, if the physician admits the patient to inpatient status, you would report the initial hospital visit codes (99221-99223, Initial hospital care, for the E/M of a patient -; or 99234-99236, Observation or inpatient hospital care, for the E/M of a patient including admission and discharge on the same date ...) in place of an ED services code. Similarly, if the physician admits the patient to observation status subsequent to the ED service, you should report only the [...]