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Family physicians (FPs) are often called when a patient is seen in the emergency department (ED). These visits can trigger a variety of coding scenarios, depending on the roles the ED physician and FP play in the patients care and whether the patient is subsequently admitted to the hospital. Among the codes that may be assigned include emergency department services codes (99281-99285), outpatient service codes (99201-99215), and initial hospital care codes (99221-99223).

Family practice coders say there are six ED scenarios they struggle with most frequently.

1. The patient is seen in the ED, but not admitted as an inpatient.
For example, a 68-year-old male is seen in the ED complaining of shortness of breath. The patient, a smoker, had recently been treated by the family physician for a respiratory infection. The ED physician asks the FP to examine the patient. The FP sees the patient in the ED, prescribes an antibiotic, and sends the patient home with instructions to make an office appointment the following week.

The FP, like the ED doctor, would report an ED service code, according to Kathy Pride, CPC, CCS-P, coding specialist for Martin Memorial Medical Group, a practice with 57 primary care physicians in Stuart, Fla. In this instance, either 99282 (emergency department visit for the evaluation and management of a patient, which requires an expanded problem focused history and examination, and medical decision making of low complexity) or 99283 (emergency department visit for the evaluation and management of a patient, which requires an expanded problem focused history and examination, and medical decision making of moderate complexity) is assigned. ED codes follow standard evaluation and management (E/M) documentation guidelines, and do not distinguish between new or established patients.

Pride notes that many family practice coders are reluctant to use ED services codes, believing only physicians assigned to the ED can report them. However, any physician seeing a patient registered in the ED may report these codes.

Additionally, she says, some private payers may pay only one physician for the same episode of care using ED codes, challenging the medical necessity of two physicians providing concurrent care. In this situation, some coding professionals recommend reporting outpatient visit codes although others note that the introductory text for outpatient codes explicitly states, For services provided by physician in the emergency department, see 99281-99285.

2. Family physician provides consultation to the ED physician.
Pride explains that consultation codes (99241-99245) may also be used in limited circumstances when the FP provides an opinion to the ED physician but the patient is not admitted to the hospital. This coding scenario must be approached carefully, however, because strict criteria govern use of consultation codes. It is to the family physicians advantage to assign a consultation code when appropriate because these codes are paid at a higher rate than outpatient codes.

If the ED physician requests the advice or opinion of the family physician, the request and reason for the consultation must be documented in the patients medical records, Pride explains. And the consultant in this case, the family physician must prepare a written report of his or her findings and provide it to the requesting ED physician.

An example of when coding a consultation might be appropriate is an emergency involving a young child. Pride notes that ED physicians are sometimes reluctant to treat young children, especially on complicated cases. They may not be familiar with pediatric dosages, treatments, etc., and therefore might contact the FP. The FP would then come to the ED, see the patient and advise the ED physician on the proper treatment, providing the proper documentation. The ED physician then treats the patient and the patient is subsequently sent home.

If, however, the FP becomes directly involved in the patients care during an emergency visit, the consultation code may not be reported, Pride says. Remember, the definition of a consultation is simply a request for advice or opinion regarding evaluation and/or treatment of a specific problem.

Note: An explanation of the proper use of consultation codes appeared in the March 2001 edition of Family Practice Coding Alert.

3. Family physician advises the ED physician by phone, but does not see the patient.
In some cases, the ED physician telephones the family physician, but the FP does not come to the hospital to see the patient. The FP would not bill for service, notes Emily Hill, PA-C, president of Hill & Associates, a coding and compliance firm in Wilmington, N.C., and member of several coding committees of the American Medical Association. Unless the family physician sees the patient in the ED, he or she is not permitted to bill for services that day, she says.

4. The patient is seen in the ED and subsequently admitted as an inpatient.
If the family physician determines the patient should be hospitalized, coders would assign alternative codes. The ED physician would assign the ED service codes, but the family physician admitting the patient would bill the appropriate initial hospital care code [99221-99223], Pride says. All E/M services provided with the hospital admission are included in theses initial inpatient codes when performed on the same date as the admission.

Coding becomes tricky if the family physician did not see the patient on the same day as the ED. For instance, a patient may be seen in the ED at 10 p.m., Pride says. The patient is stable and in no immediate danger. The ED calls the FP and, after discussing the patients condition, the FP admits the patient and gives orders by telephone. However, the FP doesnt see the patient until the next day during rounds when he performs a complete history and physical.

This next-day service may also be reported with the proper initial hospital care code (99221-99223), but only if the ED physician did not provide and report this service the previous evening. Family physicians must be diligent about providing appropriate documentation on the date that they saw the patient, Hill says. If the ED bills for the initial care, the services provided by the FP on the following day must be reported using subsequent hospital care codes (99231-99233).

5. Family physician sees patient in the office and ED on the same day.
Coding for these situations depends on the reason for the office visit. If the two visits result from the same medical condition, only one may be reported and billed. If the two visits are unrelated, both may be reported.

For instance, a 63-year-old woman schedules a morning office visit with her family physician because she has had chest pains. The pains worsen later in the day and the woman goes to the ED. The FP is called to the hospital. In this case, the FP assigns only the ED services code or the appropriate outpatient code. When determining the level of coding, work performed during both encounters should be considered.

Alternately, the same woman may have been seen in the office for a routine followup for hypertension and cardiovascular disease. Later that day, she develops chest pains and goes to the ED. Both visits can be reported, Hill says. However, diagnosis coding is vital to reimbursement because the ICD-9 codes will help distinguish the reasons for the two visits. It may also be necessary to provide documentation for both visits in order to assure reimbursement for both services.

For instance, the morning office visit is coded with the appropriate E/M code and ICD-9 codes 401.1 (essential hypertension, benign) and 429.9 (heart disease, unspecified).

The family physician would also report an outpatient E/M code or an ED service code, along with an appropriate diagnosis code (e.g., 786.50, chest pain, unspecified or 786.59, chest pain, other), if the patient is sent home from the ED. If the patient is admitted, the admission diagnosis might include the above, plus 413.9 for angina and 794.31 for abnormal findings on an ECG.

6. Family physician provides qualified critical care.
If the patient fits the definition of critically ill or injured and the physician provides critical care services in the ED, codes 99291-99292 should be utilized, Pride says.

Critically ill and unstable patients require full physician attention, whether in the course of a medical emergency or not. Critical care involves decision-making of high complexity to assess, support and manipulate the patients vital systems to prevent or treat failure of these systems. Managing critically ill patients typically requires interpretation of various data and application of advanced technology.

Note: An in-depth look at critical care codes appeared in the June 2000 issue of Family Practice Coding Alert.