TMPPM 2011 > Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook > Physician > Services/Benefits, Limitations, and Prior Authorization > Physician Evaluation and Management (E/M) Services > Physician Services Provided in the Emergency Department

8.2.57.3 Physician Services Provided in the Emergency Department

Providers must use procedure codes 99281, 99282, 99283, 99284, and 99285 when billing emergency department services.

If an emergency department visit is billed by the same provider with the same date of service as any of the following office, outpatient consultation, or nursing facility service procedure codes, the emergency department visit may be reimbursed and the office, consultation, or nursing facility visit is denied:

Emergency department visits are denied when billed with the same date of service as an observation service (procedure codes 99217, 99218, 99219, and 99220) by the same provider.

Multiple emergency department visits provided by the same provider for the same client on the same day must have the times for each visit documented on the claim form. Also, more than one visit billed with the same date of service can be indicated by adding the modifier 76 to the claim form. Medical documentation is required to support this service.

Reimbursement for physicians in the emergency department is based on Section 104 of TEFRA. TEFRA requires that Medicaid limit reimbursement for those physicians' services furnished in hospital outpatient settings that also are ordinarily furnished in physician offices. The list of emergent condition diagnosis codes is used to determine the appropriate reimbursement for these services. The reimbursement for each service is determined by multiplying the base allowable fee by 60 percent.

Refer to: Section 2, "Hospital (Medical/Surgical Acute Care Facility)" in Hospital Services Handbook (Vol. 2, Provider Handbooks) for information on emergency department services by facilities (room and ancillary).