What is the billing code for a patient (pt) sent to the Emergency Room (ER)?

Billing Code for a Patient Sent to the Emergency Room

The appropriate billing code for a patient you sent to the Emergency Room is CPT code 99288, which covers physician direction of emergency medical systems (EMS) emergency care, advanced life support.

Understanding the Appropriate Billing Code

When referring a patient to the Emergency Room, the billing process depends on several factors:

1. Primary Code Option: CPT code 99288 is specifically designed for physician direction of emergency medical systems emergency care and should be used when you direct a patient to the ER 1.

2. Documentation Requirements: To support this billing code, you must document:

   • The medical necessity for the ER referral
   • Your clinical decision-making process
   • Any communication with emergency services or the receiving facility 2

Additional Considerations

For Telephone Management Related to ER Referrals

If you provided telephone management as part of directing the patient to the ER, consider these additional codes:

• For telephone calls involving case management, medical management, and coordination of care:
  • 99371: Simple decision-making
  • 99372: Intermediate decision-making
  • 99373: Complex decision-making 2

Important Caveats

• Reimbursement Challenges: Many government payers and private health plans do not reimburse for telephone care codes even when appropriate CPT codes are used 2.

• Documentation is Critical: The Centers for Medicare and Medicaid Services notes that nearly half of all E&M visits for Medicare patients are coded incorrectly, highlighting the need for thorough documentation 1.

• Avoid Common Pitfalls:

  • Insufficient documentation of medical necessity
  • Incorrect modifier usage
  • Failure to document time spent if using time-based coding 1

Billing Process Algorithm

1. Determine if you directed emergency care: Did you provide specific direction for emergency care or transport?

   • If YES → Use code 99288
   • If NO → Proceed to step 2

2. Evaluate the nature of your involvement:

   • If you provided telephone management only → Consider codes 99371-99373 based on complexity
   • If you provided in-person care before referral → Use appropriate E&M code with documentation of decision to refer to ER

3. Document thoroughly:

   • Medical necessity for ER referral
   • Your clinical assessment and decision-making
   • Any communication with emergency services
   • Time spent if using time-based coding

Remember that proper documentation is essential not only for appropriate reimbursement but also to avoid potential compliance issues with government auditors 1.