ER Consultations for Medicare Patients – Medical Coding

ER Consultations for Medicare Patients – Medical Coding

Coach Jennifer: OK. So, our question was:
Q: “If a patient with Medicare comes in the ER and a hospitalist does a consult, do we use an outpatient code or ER codes?”
A: Well, I wanted to go over just kind of a little bit of beginning with a review of evaluation and management in CPT because in that question there were so many little … I actually kind of read that question three or four times to make sure exactly what it was they’re asking, so I just wanted to go over a little bit.
We remember that consultations effective January 2010 you can’t use them for Medicare at all. So, you’re not even billing a consultation type of E/M and it would also require a source or a request of another provider, so of course that’s not in this case if they went to the emergency room.

According to CPT, it says: “A patient is considered an outpatient until inpatient admission to a healthcare facility occurs.” So, in this case, if it was just truly an emergency room appointment, then you’re looking at an outpatient type of code versus an inpatient code.

“When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site such as the emergency room all evaluation and management provided by that physician in conjunction with that admission are considered part of the initial hospital care…” So, if the patient came into the ER or the emergency department and then was admitted, you won’t even worry about it in the ED code because they’re now an inpatient, so we wouldn’t even bill that.
Nowadays a lot of patients are going under observation instead, so they could come into the emergency room and then it’s going to wind up going into observation for possibly about 48 hours. And CPT says pretty much the same thing as the inpatient is if they came in through the emergency room, they’re put in observation, you’re going to use an observation status code. Just trying to clarify some of these codes, not exactly where they’re going with that question.

An emergency department is defined as the hospital-based facility for an unscheduled episodic service available 24 hours a day. Because in case this person who asked this question is in a rural type of area, Medicare does distinguish between a 24-hour facility, they call those Type A and then one that does not provide 24 hours service, those are Type B. Type B use a HCPCS code, not a CPT code, so a little distinction there.

If you would look at CMS, they say that the “physicians shall code patient E/M visits codes that represent where the visit occurs and that identity the complexity of the visit…” So, where did it occur? If they stayed in the emergency room, an emergency department that’s a section of CPT you’re going to use for the E/M is emergency department. If they came in to the emergency department and were put on observation, you’re going to use an observation code. If they came into the emergency department and went inpatient admission, it’s now an inpatient code.
The American College of Surgeons also stated it as well, “…if the patient is seen in the Emergency and not admitted, then use the appropriate ED code.” If there were seen in the emergency department and then admitted, you have a hospital inpatient code.
There are lots of different scenarios that i just described a little bit and then go over a little bit more. Observations are commonly ordered for patients who go to the emergency room, then require some other kind of treatment or monitoring. So, it’s typically about 48 hours. They’ll put them in an observation status. So, those are billed under initial observation by the physician who ordered that observation. You don’t have to have admitting privileges as well as another distinction that they make.
If you went from observation to hospital inpatient, now inpatient is going to take over the status of that depending upon the date of service.

If you went from the emergency room to critical care, they came in through the emergency department, they’re going to pay for an emergency department code for the same date if critical care was also given. You’re going to go with your higher complex critical care codes in that case.

Again, if you went from the emergency department to hospital inpatient, then they don’t pay for both E/M. They’re going to pay for the inpatient.

What if somebody requested a specialty consultation, then there’s a different coding scenario for that as well. The specialist who came in and did the consult is now going to admit them to the hospital then he’s the one who’s going to bill for that code.
Then it also said a hospitalist, so we want to make sure that we’re distinguishing that any physician seeing a patient in the emergency department, they can use those emergency visit codes. They don’t have to be strictly assigned to the emergency room. A hospitalist, internist,