CSHCN Services Program 2011 > Physician > Benefits, Limitations, and Authorization Requirements Emergency Services

An emergency medical condition is defined as a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) that if not immediately treated must reasonably be expected to result in one of the following outcomes:

Placing the client's health in serious jeopardy

Serious impairment to bodily functions

Serious dysfunction of any bodily organ or part

An emergency department is defined as an organized hospital-based facility for the provision of unscheduled episodic services to clients who require immediate medical attention. The facility must be available to provide services 24 hours a day, 7 days a week.

Hospital-Based Emergency Department Professional Services

Physicians may use procedure codes 99281, 99282, 99283, 99284, and 99285 to bill for services provided in the hospital-based emergency department. Office-based physicians may also use procedure codes 99201, 99202, 99203, 99204, and 99205 for new patients or procedure codes 99211, 99212, 99213, 99214, and 99215 for established patients, to bill for services provided in the office or in a hospital-based emergency department. These procedure codes are also appropriate for a physician who is attending a client in an outpatient observation room setting for less than 6 hours. Document the time for multiple visits in Block 24K of the CMS-1500 paper claim form.

Emergency department visits include the components of a diagnostic examination such as a pelvic or rectal examination. These components should not be billed with an unlisted procedure code in addition to the procedure code for the visit. These components are considered part of the examination and no separate reimbursement may be provided.

Multiple emergency department visits on the same day and billed by the same provider must have the times for each visit documented on the claim form. More than one visit on the same day can also be indicated by adding modifier 76 to the claim form. Medical documentation is required to support this change.

Emergency department visits may be paid to different providers on the same day, when medically necessary, regardless of specialty and diagnosis.

Separate charges are allowed for emergency department treatment room and minor surgery or diagnostic procedures billed on the same day. Use the appropriate procedure code from the CPT manual.

Payment for an additional emergency department visit by an anesthesiologist following a surgical procedure is denied as part of the global anesthesia payment (base plus time). A distinct and separate diagnosis beyond the diagnosis for which the global anesthesia services were provided should be documented in order for payment to be considered on an appeal basis.

If an emergency department visit (procedure codes 99281, 99282, 99283, 99284, and 99285) is billed on the same day, by the same provider, as an office visit (procedure codes 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215), or outpatient consultation (procedure codes 99241, 99242, 99243, 99244, and 99245), the emergency department visit may be considered for reimbursement and the office or consultation visit is denied.

Emergency department visits (procedure codes 99281, 99282, 99283, 99284, and 99285) are denied when billed on the same day as an observation service (procedure codes 99217, 99218, 99219, and 99220) by the same provider.

Critical care provided on the same day as an emergency room visit may be billed when the services are rendered during a separate encounter. Medical documentation is required to support this charge.

Binocular microscopy (procedure code 92504) and noninvasive ear or pulse oximetry for oxygen (procedure code 94760) will be denied when billed on the same day, by the same provider, as emergency department visit (procedure code 99281, 99282, 99283, 99284, or 99285).

Texas Medicaid & Healthcare Partnership
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