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Orthopedic Coding Alert

READER QUESTIONS:

Confirm Whether ED Visit Qualifies as Consult

Question: A hospital ED physician asked my on-call orthopedic surgeon to admit a patient. He spent an hour with the patient at the hospital but didn't admit her. Normally, he sends patients from our office to the hospital and I report an outpatient E/M code. Should I use emergency department services codes instead because the hospital contacted the surgeon?


Wisconsin Subscriber


Answer: If the emergency department (ED) physician asked the orthopedist to evaluate the patient, your surgeon most likely performed an outpatient consult, which you should report using a code from the 99241-99245 series (Office consultation for a new or established patient ...). 

In your case, the ED physician probably admitted and discharged the patient from the ED. If that is the case, then the ED physician probably reported a code from the 99281-99285 series (Emergency department visit for the evaluation and management of a patient ...) for his services, and your surgeon should report his consult separately, assuming he met the requirements of a consultation.

If that is not the case, and the orthopedist discharged the patient from the ED himself, he will most likely have to report a code from the 99201-99205 or 99212-99215 E/M series (Office or other outpatient visit for the evaluation and management of a patient ...).

If your surgeon charges one of these E/M codes and the ED physician bills 99281-99285, the insurance carrier will most likely only reimburse one physician for these codes when both are involved in the patient's care during the same ED visit.

Remember: You cannot use initial hospital care codes (99221-99223) or subsequent hospital care codes (99231-99233) because neither the surgeon nor the ED physician admitted the patient to the hospital.

Follow these tips: If the ED physician called your surgeon into the hospital to provide a consultation and your surgeon did not take over the patient's care, you should report an outpatient consultation. You must, however, have proper documentation that supports the consultation claim in the patient's chart.


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