E&M and the Emergency Room

I have a general surgeon that goes to the Emergency Room to see a patient. The ER physician has asked him to come and do the consult. The GS admits the patient to the hospital and then does surgery on the patient what E&M do I code?

E & M adnt the Emergency Room

99281 thru 99285

emergency room visit

When I see a patient in the ER and take them to the OR I'll code depending on the situation...if it was a clear cut case, as may happen if the ER doc already ordered a CT which showed appendicitis, then I'll write admitting orders, dictate an H&P and then take the patient to the OR...I'll code this E&M as an admission (99221-99223) with -57 modifier. If the ER doc doesn't really know what's going on (or they're not sure) then I'll code this as an outpatient consult (99241-22945) with a -57 modifier. If I see the patient and discharge them home, then it'll be either a consult (99241-99245) or ER service 99281-99285 depending on the situation...can anyone confirm if this is close to acceptable.

What category of code?

I agree with the above comment.

If the surgeon is asked for a consult from the ED doctor, the surgeon may bill an outpatient consult. If the patient is admitted to the surgeon's service, the surgeon may still bill the outpatient consult (that was the patient's status at the time of the request, the consult requirements are met) however, if the note is headed, "Admission" bill an admission.

The billed code should match the documentation.

Er

According to Medicare he can bill an inpatient consult (99251-99255) or an inpatient admission (99221-99223) based on level of service documented, The -57 modifier is placed on the E/M code billed, if the surgery is that day or next day.

ER consult

My understanding is that ER consults are considered outpatient consults, because the patient hasn't been admitted yet. Therefore, I don't see how a consult in the ER can be billed as an inpatient consult.

ER Consults

You are correct in reporting the 99241-99245 CPT codes when a consultation service is pefformed in the ER and the consultation requirements are met. According to CPT, a consultation service performed in the Emergency Department is reported using the outpatient consultation CPT codes. The source is found in the 2009 CPT Manual in the consultation guideline instructions. An excerpt from the guideline section follows, "The following codes are used to report consultations provided in the physician's office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, or emergency department..." This citation is found in the consultation guidelines.

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My worry is...

that the MAC computers will see a patient with an Inpatient hospital claim and an Outpatient MD claim for the same date and reject the claim as inconsistent. I favor billing the ED consult on a patient that is subsequently admitted as an inpatient consult.

ED/consult

Medicare has what is known as the Common Working File. A patient designated as an inpatient at 12 midnight for the date of service, cannot also be an outpatient on that date. All E/M oupatient codes are bundled into hospital physician service. For that reason, either/or (admit or inpt consult) is allowed by Medicare

E/M and the Emergency Room

If your physician does the admit, they would charge an admit code 99221-99223 for in patient with modifier 57. The rule is only one E/M vist per day for the same problem, look at the CPT book under the admit codes. If the patient is only in the ED you can use the ED codes or the new/established patient codes with the modifier 57(for 90 global) 25 for 0-10 day global). You have to be careful using the consult codes when requested by the ED physician because the rules for Consults are the three R's, Request, Render and Respond. It is the third one that has trouble in the ED because when the ED physician calls in a specialtist do they want your opinion or turning over care. The documentation must show the intent of the request is for advice and opinion on treatment of the patient.

here we go again

Here we go again...Maybe its a good thing that CMS is doing away with the consult codes. The decision as to whether this is a consult has to do with intent. Intent can be interpreted differently. As a general surgeon I'm frequently asked to see a pt in the ER by the ER doc for "abdominal pain" or supposed bowel obstruction...Half the time the ER doc doesn't know what's going on. You can interpret this in one of two ways.....1) Come take over this patients care because I don't know what to do. Or 2) Come tell me what's going on and what needs to be done because I don't know what to do. Am I supposed to ask the ER doc which one it is he is asking for? In real life it doesn't work that way. So, at the risk of sounding arrogant, ...a consult is a consult when I think I'm being asked for a consult. That might not meet the CMS definition, but perhaps that's exactly why CMS is doing away with consult codes....BECAUSE NO CLINICIAN REALLY GETS IT.