Health Information Management

When to bill an ED E/M facility charge with a procedure

APCs Insider, June 2, 2006

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When to bill an ED E/M facility charge with a procedure

QUESTION: I have a two-part E/M question:

Part one: A patient with a laceration comes to the ED. The ED physician sutures the laceration and performs no other services (e.g., no x-rays, gives no medication). Our consultant says to only code the suture and not charge an E/M level. Is this correct?

Part two: A patient presents to the ED in cardiac arrest undergoing CPR. The patient never regains consciousness and expires within 10 minutes. Our consultant says to code CPR, but not an E/M level because the patient never regained consciousness. Is this correct?

ANSWER: First of all we need to clarify that you are billing for the facility and not the physician. The answers could be different depending on whose behalf you are billing. The following answers are based upon facility rules.

Part one: If a patient arrives at the ED with a laceration he or she will be evaluated prior to the closure of the laceration. For example, how do you know the patient doesn't need x-rays? It is likely the physician reached this conclusion after an interview with the patient and an exploration of the wound. Furthermore, most lacerations are not closed without at least a local anesthesia. In summary, it is unlikely that a patient comes through the door of the ED and moves immediately to the table for suturing. This means that the facility should charge an appropriate E/M charge based upon your criteria for resource consumption.

The answer as to whether a facility E/M code is separately identifiable from the procedure is based on two factors:

  • the documentation
  • the hospital's ED E/M guidelines for one of the five E/M facility levels (99281-99285)

For example, the patient was likely:

  • triaged by an ED nurse
  • registered by staff
  • assessed by an ED nurse in the ED bay after the patient was moved from the waiting room

These elements are likely included in the hospital's ED E/M guidelines, and depending on the documentation of these services, these services could qualify for a separate E/M code in addition to the laceration repair CPT code.

The only exception to this may be a scenario where the patient is seen at a physician's office, but for some reason the physician doesn't suture the patient. For example, the patient and physician arrive at the ED and bypass the normal process. The physician sutures the patient without performing a re-evaluation. For this scenario, it may be appropriate to bill a procedure charge without the E/M code.

Part two: A patient does not have to be conscious to justify a facility E/M charge. Based upon the resource consumption of that patient during the 10 minutes this would certainly justify a high level E/M code. Because of the short duration of the encounter your FI may not allow a critical care charge (99291) in place of the E/M code, but depending on the circumstances and who your FI is, you may find that a critical care code is more appropriate than an E/M code.

Again, depending upon documentation and hospital ED facility charging policy, the hospital may have initiated the trauma team and expended other significant resources beyond the CPR procedure. These services, if appropriately documented and addressed in policy, would likely support a facility charge for critical care in addition to CPR (92950).

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