How to Bill an E/M Service Provided by a Non-Emergency Medicine Provider...

March 10th, 2009 - Seth Canterbury, CPC, ACS-EM
Categories: Coding CPT^® Coding Evaluation & Management (E/M) Medicare

How to Bill an E/M Service Provided by a Non-Emergency Medicine Provider Who:

a) Did Not End Up Admitting the Patient, and

b) Was Not Consulted

Per CPT®, any physician can bill an ED E/M code, but if two physicians both see a patient in the ED, and one of them is an Emergency Medicine specialist, CPT® (in the summer 1995 and January 2002 CPT® Assistants) says that the EM provider should be the one billing the ED code and the other physician will either bill an admission, consult, or an office/other outpatient visit code. Per the January 2002 CPT® Assistant: “for any single ED patient visit, only one physician can report an ED E/M code.”

So for those payers that give no specific direction that contradicts established CPT® coding instruction, a code from the New/Established Office/Other Outpatient Services range (99201-99215) should be billed as appropriate for a non-ED provider seeing the patient in the ED

1. if the patient was already seen by an ED provider, and

2. if the second provider

a) is not admitting the patient, and

b) was not consulted (usually they were just asked to come manage/treat

the patient)

Medicare, however, gives different instruction that contradicts CPT’s direction. They say that the provider contacted by ED to see a patient (but who was not consulted for an opinion and does not admit the patient) should bill the encounter using one of the ED E/M codes:

Medicare Claims Processing Manual

Chapter 12 - Physicians/Nonphysician Practitioners

F. Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting

“If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are met. If the criteria for a consultation are not met and the patient is discharged from the Emergency Department or admitted to the hospital by another physician, the physician contacted by the Emergency Department physician should bill an emergency department visit.”

Presumably (but not entirely certain based on Medicare’s manual instruction), the ED physician would still bill an ED series code to Medicare as well if they performed an E/M service prior to the second provider’s service, as Medicare does sometimes allow two providers to bill ED codes for the same patient on the same day. That’s not to say that a particular Medicare carrier doesn’t have an edit that will try to deny the charge on the front end. They may, and an appeal may be necessary to get paid for both services. To improve chances of reimbursement, the documentation should reflect the medical necessity of both encounters.

### Printed: June 12th, 2026
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