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Coding corner

Billing in the ED and transitional care units

By Brian Whitman

From the August ACP Hospitalist, copyright © 2008 by the American College of Physicians

Sidebar: At A Glance

Q: If I am called to the emergency department to consult for possible admission and the patient is not admitted, can I bill for the services?

A: Yes, you may bill for services in this circumstance. The appropriate code to be billed depends on the nature of the request received. In most cases, the most appropriate code would be an outpatient consultation (CPT codes 99241-99245). These codes apply only if the ED physician requests your opinion on an issue and you communicate a recommendation back to him or her. If the ED physician does not make such a request, then a consultation could not be billed, but an ED visit (CPT codes 99281-99285) could be.

Q: How should I bill for evaluating a patient who is in a transitional care unit after being discharged from the hospital? What if I re-admit the patient to the hospital or to a nursing facility?

A: Care provided in a transitional care unit is typically considered part of either the discharge or the initial visit at the next facility to which the patient is transferred.

For example, your patient is discharged from the hospital and placed in a transitional care unit so you can monitor him to determine the next step in his care. At the transitional unit, you evaluate him and admit him to a nursing facility. Upon his admission to the nursing facility, you perform a comprehensive nursing facility assessment. You should bill only for the comprehensive nursing facility assessment, selecting a level of service that accounts for the complexity of the service performed in the transitional care unit (CPT 99304-99306).

If your patient is not admitted to a nursing facility, you should consider the transitional care services part of the initial hospital discharge services.

You can bill CPT 99499, unlisted evaluation and management service, if you believe that you provided a separate service in the transitional care unit. However, you need to submit a written report explaining how the service is not captured by an existing CPT code, and it may be difficult to receive payment.

If a patient is in a transitional care unit for an extended period, check with the hospital or other facility to see how it classifies its transitional care unit.

Brian Whitman is Associate for Regulatory and Insurer Affairs in ACP’s Washington, D.C. office. His column appears every other month. E-mail coding questions or issues to acphospitalist@acponline.org.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated