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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.56 Physician Evaluation and Management (E/M) Services : 9.2.56.3 Physician Services Provided in the Emergency Department

9.2.56.3
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 code 99217) 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 appropriate modifier 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 nonemergent and nonurgent physicians’ services furnished in hospital outpatient settings that also are ordinarily furnished in physician offices. The emergency department procedure code that is submitted on the claim is used to determine the appropriate reimbursement for these services. The procedure code billed may include, but is not limited to, E/M, surgical or other procedure, or any other service rendered to the client in the emergency room. The procedure code must accurately reflect the services rendered by the physician in the hospital’s emergency department. The reimbursement for each service is determined by multiplying the base allowable fee by 60 percent.
Refer to:
Section 4, “Outpatient Hospital (Medical and Surgical Acute Care Outpatient Facility)” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for information on emergency department services by facilities (room and ancillary).
Subsection 2.2.1.1, “Non-emergent and Non-urgent Evaluation and Management (E/M) Emergency Department Visits,” in Section 2, “Texas Medicaid Fee-For-Service Reimbursement” (Vol. 1, General Information) for more information.

Texas Medicaid & Healthcare Partnership
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