Health Information Management

Q&A: Billing ED codes for trauma physicians

JustCoding News: Outpatient, December 2, 2009

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QUESTION: I bill for trauma physicians, and often they see patients in the emergency room at the request of the emergency department (ED). May I bill using the ED codes?

ANSWER: It most likely depends on if you are consulting CMS or the AMA. The AMA’s CPT Assistant, July 2002 states that “only one physician can report an [ED evaluation and management] code.”

However CMS states the following in the Medicare Claims Processing Manual, chapter 12§30.6.11, F:

ED physician requests another physician to see the patient in ED or office/outpatient setting

If the ED 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 ED or admitted to the hospital by another physician, the physician contacted by the ED physician should bill an ED visit. If the consulted physician admits the patient to the hospital and the criteria for a consultation are not met, he/she should bill an initial hospital care code.

Check with your local carriers to determine their preference for reporting.

Note: In the 2010 Medicare physician fee schedule final rule, CMS decided to eliminate payment for consultation services (CPT codes 99241–99255). Further guidance is expected from CMS on the reporting of “consultative” services in the ED when an admission does not occur by that physician.

Editor’s note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA, answered this question.

This answer was provided based on limited information submitted to Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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