Subspecialty Corner: Coding for the Primary Care Pediatrician in the Emergency Department

Abstract

At times, the primary care pediatrician may have to care for a patient in the emergency department (ED). When this occurs, what is the appropriate way of coding for reimbursement? The code(s) you use will depend on the following factors:If you have arranged for a patient to meet you at the ED and you are the physician primarily managing the patient, you should use the ED evaluation and management (E/M) codes. The ED E/M codes may be used by any physician who provides services in an ED. An ED is defined for Current Procedural Terminology (CPT) purposes as a specified area of a hospital available 24 hours a day for the provision of unscheduled care for conditions that require immediate medical attention. A freestanding urgent care center, even if owned by a hospital, does not qualify for use of the ED E/M codes.The ED E/M codes differ from office visit codes in several ways. First, it does not matter if the patient is new or established. Second, the codes have no time values associated with them. The amount of physician work per code level is not exactly equivalent to the outpatient visit codes (Table 1). Additionally, make sure that ED is listed as the site of service on your bill; third-party payers will reject billings with ED E/M codes that are pointed to a non-ED site of service.You should not code for 99056 (service provided at request of the patient at location other than physician’s office); this code is meant to be used for care given in a location where office-type medical services are not routinely performed (eg, patient’s office).When you are called in by the ED physician to see a patient, the type of service you code for will depend on whether you are providing consultative services or taking over the management of the patient. You should use the outpatient consultation codes when providing an opinion or advice (including the initiation of diagnostic and/or therapeutic services) to the requesting physician. Consultations, like ED E/M codes, are provided regardless of whether the patient is new or established for you or your group. There are, however, time values associated with these codes (Table 2). There must be an order by the requesting physician (or other appropriate source) for the consultation. The consultant must document the provided services in the medical record and by written report to the person who requested the consultation. If the request for consultation was made verbally, the consultant should document this in the report.For those patients for whom you take over care and management, use of the ED E/M codes is appropriate. More than one physician may provide similar service to the same patient on the same date. The CPT codes no longer include a modifier to indicate when concurrent service occurs. In either case, be sure to use the ED site of the service identifier.For those times you only provide advice to the ED physician by phone, you may use the telephone care management E/M codes. These codes are based on the complexity of care, amount of information reviewed, and length of the call (99371: simple/brief, 99372: intermediate, 99373: complex/lengthy). The details and length of the call must be documented in the medical record.If you are providing management for any critically ill or injured patients, the critical care codes (99291–99292) may be used. A critically ill or injured patient is one who has acute impairment of one or more vital organ systems with a high probability of imminent or life-threatening deterioration. Except in life-threatening situations, critical care usually involves the use of advanced technologies and interpretation of multiple physiologic parameters. The critical care codes are exclusively time based. The time spent providing critical care does not need to be continuous and includes time at the bedside as well as reviewing data specific to the patient, discussing the patient with other physicians, and discussing matters with the family that involve the patient’s management. The time reported for critical care must be spent on the individual patient; your critical care clock stops when dealing with another patient. You also must be readily available in the unit in which the patient is receiving care. The total amount of time spent providing critical care services should be documented in the medical record.Certain procedures are bundled or included with critical care codes. These include certain vascular access procedures (intravenous [IV] start [36000], venipuncture in child older than 3 years requiring physician skills [36410], routine heel or finger stick [36415], collecting blood from an implanted venous access device [36540], and arterial puncture [36600]), vent management (94656–94657, 94660, 94662), temporary transcutaneous pacing (92953), gastric intubation (placement of nasogastric/orogastric tube by physician) (43752, 91105), interpretation of blood gases, pulse oximetry (94760– 94762), and chest x-rays (71010, 71015, 71020). Procedures such as starting an IV on a child younger than 3 years, placing an intraosseous or central venous line, endotracheal intubation, cardiopulmonary resuscitation (CPR), and cardioversion are not bundled with the critical care codes and should be billed separately.You must spend at least 30 minutes of time on critical care to be able to bill for critical care services. Time spent performing non-bundled procedures (eg, CPR, intubation) may not be included in the determination of amount of critical care time. Code 99291 is used for the first 30 to 74 minutes of critical care time, while 99292 is used for each additional 30 minutes. New to CPT rules this year is a clarification that the same physician may bill a separate E/M code on the same day that critical care services are provided.Whether providing ED critical care or consultative E/M services, you may code for any separately identifiable procedure(s) that you personally perform. Documentation must be provided in the medical record for every billed procedure you provide. Unlike the office setting, however, you may not charge for services or procedures that are provided by the hospital staff or for equipment that you do not control. The “incident to” rule that is commonly used in the office to bill for services provided by patient care staff does not apply in the ED. You also may not bill for the use of equipment that is owned by the hospital (eg, pulse oximetry); the interpretation of pulse oximetry is considered part of the ED E/M service. A -25 modifier is added to the E/M code when coding for any separately identifiable procedure that is performed at the time of the E/M encounter.All of the codes mentioned can be used whether the patient is discharged from the ED or transferred to another facility. If you admit the patient to the hospital for observation or inpatient services, use the appropriate observation or inpatient hospital visit code and not the outpatient service code. This also would apply if the patient is transferred to another facility to be under your care (or the care of a member of your group). You only may bill for a single E/M service per calendar day, except for critical care and a few other exceptions not related to this topic.When providing services in the ED, you cannot use any special office service codes. The codes for services after office hours (99050), between 10:00 pm and 8:00 am (99052), Sundays and holidays (99054), and on an emergency basis (99058) are meant for use only in the office setting during times when the office is not usually open and staffed (ie, outside of posted office hours).The primary care pediatrician often is called on to provide care and advice for the management of children in the ED. By understanding the differences between office and ED coding, you can appropriately code for reimbursement for services provided in the ED.