A Minute for the Medical Staff
A supplement to
medical records briefing
August 1999
Emergency! ER codes misused and abused
Simple rules for staying out of trouble
“I would say that a high percentage of non-ER doctors
coding in the emergency room are coding incorrectly’”
says Diane Jepsky, RN, MHA, a president and CEO
of Jepsky Health Care Consultants in Issaquah, WAS
and a former emergency room nurse.
The misuse of ER evaluation and management (E/M)
codes also occurs outside the emergency room, Jepsky
notes—a particularly troubling situation.
According to coding rules, Jepsky points out, ER codes
“should only be used in true hospital-based emergency
facilities that are open 24 hours a day and deliver
unscheduled episodic care to patients who present for
immediate medical attention.”
How ER coding mistakes happen
According to Jepsky, problems in ER coding arise
when private physicians see their patients in the
emergency room instead of their offices. Any
physician can use ER codes—as long as the service he
or she is providing is part of a true emergency.
“You can’t use ER codes when seeing a patient in the
ER as a matter of convenience,” Jepsky says. For
example, “Billy’s mom calls and says that Billy has a
sore throat. The physician decides to meet Billy and
his mom in the ER to check out the problem as it is
more convenient for the patient and the physician. In
this case, the physician should use outpatient codes
(99211-99215), assuming the patient is established,”
Jepsky explains.
Another scenario that leads to inappropriate use of ER
codes occurs when the ER physician calls in a
specialist for a consultation.
For example, the ER physician asks for a surgical
consult for a patient with abdominal pain. If this
patient is ruled out as a surgical candidate and the ER
physician discharges the patient to home, the surgeon
should use the outpatient consultation codes (9924199245), Jepsky says.
But if the patient with abdominal pain becomes a
surgical patient and is admitted to the hospital, a
transfer of care has taken place. In that case, Jepsky
says, the surgeon should code the appropriate
admission code (99221-99223). The consultative work
done in the ER is rolled into the admission and the
consult codes should not be used in addition to the
admit codes.
Jepsky points out that there are times when the ER
physician and the private medical doctor will both use
the ER codes. For example, the ER physician may see
the patient first and then call in the private physician
and transfer care over to her or him. If the private
physician elects not to admit the patient, and
discharges the patient to home, then the physician may
also use an ER code.
“Just remember that even though the providers are
different, two ER codes hitting an adjudication system
with the same date of service may cause the bill to
suspend, deny, or pay on the first bill submitted, which
may not be the appropriate bill, “ Jepsky says.
Problems outside the ER
“One of the bigger problems I see is doctors using ER
codes when they see patients emergently in their
office,” Jepsky says.
In such cases, physicians should use outpatient codes
plus the add-on code 99058, which indicates that the
patient was seen emergently.
Walk-in/urgent care centers are also susceptible to
these coding errors. While care provided in these
centers may be urgent, walk-in centers do not meet the
definition of emergency departments. Outpatient
codes (99201-99215) should be used.
Understanding correct ER coding
That said, here are some basic rules and tips for correct
sue of ER codes in reporting E/M services:

Know the codes. The following codes are used to
report E/M services provided in the emergency
department: 99281-99285. The place of service
(POS) code for the emergency department is 23.
If codes 99281-99285 are used with a POS code
other and 23—indicating that the services were
provided in a setting other than an emergency
room—then the codes are incorrect.

Check your charge tickets. Outpatient facilities
such as physician offices and outpatient facilities
should remove ER codes (99281-99285) from
their charge tickets. If the physician sees a patient
in the ER and the situation meets the requirements
for using the ER codes, the physician can write the
code in on the charge ticket.

Educate the physicians. Makle sure hospital
physicians know the rules. Inform them that
unless they’re seeing a patient in the ER truly for
an emergency, they should use outpatient or
consultation codes.

Audit the coders. Many hospitals use outside
coding companies in the emergency departments.
Jepsky notes that coding companies today often
undercode because they don’t grasp the total
clinical picture of the ER patient and they fear
compliance issues. “A lot of them fear the higher
code levels and dampen out the profile in the ER,”
Jepsky says. “They code too conservatively and
lose revenue for the ER.” She recommends
auditing ER coding at least once a year.

Put well-trained coders in charge. ER coding is
complicated because there are more procedures
done in the ER than in other departments, Jepsky
notes. Coders assigned to the ER should have a
more sophisticated understanding of coding and
medical terminology. “It’s important to have
someone who is oriented to what’s going on in the
ER and has a good rapport with the ER
physicians,” Jepsky says.
E/M documentation tips
Lynne Northcutt-Greager, CPC, of the MGMA
Health Care Consulting Group in Englewood, CO,
says that a common problem with physician
documentation is confusing the review of systems
(ROS) with the physical exam or the history of present
illness.
“They physicians that I find who are most successful
with documentation are breaking up the different
sections—chief complaint, history of present illness,
(ROS), and past family and social history—in their
progress notes,” she says. “It seems to help them
channel their thinking.”
And if your practice’s physicians depend on forms or
checklists to assist with gathering information,
Northcutt-Greager warns that you need to clearly note
the date of service on the forms. “Checksheets need to
have the patient’s name on it, and should have the date
on it,” she says.
And the major elements to accomplish this task include
writing about the disease processes that are getting
better but are not yet good enough for discharge
and writing about the ones that have developed
since hospitalization and need further work.
Utilization reviewers have tools such as “intensity of
service” and “severity of illness” criteria that can help.
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