Health Information Management

Do not bill E/M level and critical care charge for ED patient

APCs Insider, December 16, 2005

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

Do not bill E/M level and critical care charge for ED patient

QUESTION: We would like clarification regarding when we can bill critical care charges to emergency department (ED) patients. We use a point system to assign E/M levels, and if the point system is high enough, we bill a critical care charge to the patient as long as the documentation supports it. In addition if the patient was a trauma patient who arrived by emergency medical services, we charge him or her a trauma code charge for the additional resources that he or she consumed.

Currently, we charge either an E/M level or critical care charge in addition to the trauma charge, when appropriate. Our charge analyst says that we should charge an E/M level, a critical care charge, and a trauma charge. Do you know of a reputable resource for critical care charges?

ANSWER: Remember that CMS considers "critical care" an E/M service and pays it with an E/M APC, which means the E/M facility level is accounted for with the critical care facility fee. For this scenario, charge the critical care code and the trauma activation charge, when appropriate. Do not charge an additional E/M level.

The 2000 OPPS final rule states that you can only bill one E/M in this instance. The American College of Emergency Physicians Web site is a great place to go for other OPPS questions regarding the ED. You can find it here:

Remember, as with facility E/M guidelines, critical care has a different definition under physician billing guidelines. You are correct to add the critical care to your points system, but be sure to test it prior to implementation. Your system should not allow non-critical patients to accumulate enough points to be assigned critical care.

Note that Medicare does not separately pay for the trauma charge; however, you should charge it to Medicare and all payers. Some commercial payers do separately pay for it. Some states also have special trauma funds that pay the separate trauma activation fee directly or through the Medicaid program.

Research your state regulations and talk with your largest commercial payers. It is likely they have guidelines for assigning the trauma charge. For example, your facility may require a trauma designation, or you may need a trauma team that you can activate when a trauma patient arrives in your facility. Use revenue code 68X for trauma activation charges.

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular