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Question: I am relatively new to emergency department (ED) coding, and I鈥檝e heard a few colleagues talking about EMTALA. I have coded other specialties, but I don鈥檛 know anything about EMTALA. Can you please explain the concept, and tell me how it pertains to CPT^庐 coding?

Tennessee Subscriber

Answer: EMTALA, or the , is a law designed to ensure that everyone has access to emergency services regardless of whether they can pay in Medicare-participating EDs. It is then up to the coder to report these EMTALA visits as accurately as possible. If the patient cannot pay, the provider may still be able to recoup payment from insurance or government programs.

It鈥檚 not surprising that you haven鈥檛 heard much about EMTALA if you haven鈥檛 been in ED coding for long; Medicare designed EMTALA for emergency medicine only.

H&P a must: In order to be EMTALA-compliant, the ED physician must perform a history and physical examination (H&P) in order to decide whether the patient needs treatment. EMTALA refers to this service as a medical screening examination (MSE). You鈥檒l report this service with an ED evaluation and management (E/M) code (99281 [Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional] through 99285 [Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making]). This will satisfy EMTALA鈥檚 MSE requirement, which states 鈥渢hat anyone coming to an emergency department requesting evaluation or treatment of a medical condition, receives a medical screening examination,鈥� according to the Office of Inspector General (OIG) web page on EMTALA.

鈥淚f they have an emergency medical condition, the hospital must provide stabilizing treatment, regardless of the patient's insurance status or ability to pay,鈥� according to the OIG. Coders must also be ready to report any of the procedure codes that might be needed to properly report a potential EMTALA encounter. The ED鈥檚 CPT^庐 coding cannot vary based on a patient鈥檚 ability to pay, insurance status, demographics, etc.

Potential penalties: If an ED is found to have violated EMTALA, it could be subject to civil monetary penalties (CMPs).

Chris Boucher, MS, CPC, Senior Development Editor, AAPC