NAMAS Webinar Q&A: The Complexity of the ED Visit, 05/04/2021

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

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Below are the questions received during our recent webinar, Complexity of the ED Visit, originally presented on May 4, 2021. These questions have been answered by the webinar presenters, Dr. Hamilton Lempert, MD, FACEP, CEDC and J. Paul Spencer, CPC, COC.

Question 1:
How would an encounter be coded if a patient started in the ED and then subsequently is admitted as Inpatient on the same day. What happens to the ED services such as procedures-infusions and the E/M?
Answer 1:
If the ER physician performs both services, the ED E/M would be folded into the admission, with procedures still eligible to be billed. If you have an ER physician and a hospitalist, obviously each would bill for their portion

Question 2:
I should have been a little more specific on the 93005 and 93041,  we only bill facility side on these,  are we allowed to do that along with the PRO FEE 93010.  We do not bill PRO fee for the 93005 and 93041, only facility, and it is the same for the pulse OX,  can we bill the facility side for 94760 and 94761. 
Answer 2:
It is generally understood that 93010 is a professional service, and the other two are facility services. As for pulse oximetry, from a professional services standpoint, it should probably never be considered for billing, Facilities would need to make that determination based on facility billing standards.

Question 3:
How do you handle a 99285 being billed when all three components have been meet within history, exam and mdm?
Answer 3:
Medical necessity is the overarching criterion for the selection of a level of service. If the acuity and complexity of the patient's condition match a 99285, then a 99285 can be selected.

Question 4:
if a patient is seen in the emergency room and Provider charges a 99284 an later in visit different specialty sees the pt as a consult in ED which code is appropriate? Obs or consult?
Answer 4:
A consultation would be more appropriate in this case,.

Question 5:
My question is regarding risk. Do you feel that an order for MRI without contrast is minimal risk? with contrast is low risk?
Answer 5:
This is a safe path, given what is currently in place with the table of risk for these services.

Question 6:
observation admit status : If we are not the admitting provider and what rules apply, will we bill sub. obs. code or out patient code? Could you go over the guidelines
Answer 6:
If the patient is in observation status, you can bill subsequent observation codes provided that an initial observation service was billed the day prior and the patient remains in that status.

Question 7:
We have a Psychiatric Emergency department, and inpatient psychiatric floor. This place does not have an observation status, so we cannot use those codes. However, we have patients who come to the ED, and they need to stay a day or two, until they are stable to be discharge into the community. For the follow up days we use the 99212-99215 codes with place of service 23, since we do not have observation status approved for this place. Some payors do not want to pay the 99212-99213's with place of service 23.
Answer 7:
For those payers who will not recognize outpatient established E/MN with ED POS 23, consider just reverting to 99281 thru 99285, as no distinction is made between new and established patients in the emergency department, and technically, this is correct.

Question 8:
We've seen several payors state they will downcode a level 4 or 5 to level 3 based on dx. Any suggestions to appeal this type of denial?
Answer 8:
If the acuity and complexity, in your judgment, is of moderate complexity, and a detailed history and examination is documented, appeal the determination, and consider demanding a peer-to-peer review until the carrier in question relents.

Question 9:
I've seen several MDM templates based on Management options to determine the MDM level for pro fee visits- many times patients could have multiple labs and a pain med could support a Level 4. What do you think of these templates and should they be used? vs using the CMS table of risk?
Answer 9:
Consider utilizing the NAMAS Emergency services Audit Tool, which has been exhaustively researched, and is available on our website.

Question 10:
What needs to be documented by the ED provider for the subsequent days. A subsequent exam & mdm with time spent?
Answer 10:
This question is a bit amorphous, as I am not sure what is being referenced here with the term "subsequent days"

Question 11:
When billing initial observation codes is there a CMS guideline stating these codes are allowed in place of service ED(23)?
Answer 11:
It is generally accepted that observation is a patient status, and not a place of service. Medicare bases their reimbursement policies for professionals and facilities with this in mind. If your facility allows for observation status, then the services can be billed.

Question 12:
With CMS’s relaxation in who can document history, if an NP or PA documents the history (does the face-to-face intake with the patient), and the patient is then evaluated by the physician, does the visit then become subject to the incident-to rule?
Answer 12:
Incident-to is only valid in the office setting.
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