16 October 2007

Important CPT changes affecting ER Docs

The 2008 CPT book is out. For the past few years, there has been some controversy about ER docs using IV infusion codes in the ER. The language did not expressly prohibit it, and some payers would actually reimburse for it (though not all), so many ER doctors added these codes into their charge master.

For our part, we did not. There were several reasons. First of all, the documentation requirements are, not exactly onerous, but detailed enough to represent a significant obstacle to compliantly billing for that service. It would require a fair amount of attention and education of our doctors to ensure that the charting matched the charges, but doctors these days are absolutely overwhelmed with "educational mandates" like patient satisfaction, joint commission, quality and "pay for performance", and even some actual medicine, too. People only have so many incoming information channels, and doctors are saturated. So I preferred to focus on maximizing the documentation of the more "legitimate" and common services like critical care and fracture care, which in the end are far more valuable.

Also, I rather suspected that IV infusion was never intended to be a code for ER doctors to use, and that it was an oversight which would be corrected. For a doc in an office or a chemotherapy infusion center, there are costs to be covered and in the absence of a separate E/M charge, the infusion code represents the entirety of the physician work, which should be reimbursed. But in the ER, the facility bears the overhead of the infusion, and the infusion is really just accessory to the diagnosis and management work, so it doesn't make sense to reimburse for it as a separate line item.

And I have been proven right (yes, it does happen on rare occasion). The new language of the "Hydration , Injection and Infusion" codes does appear to preclude further use in the ED setting. Page 383 reads:

“Physician work related to hydration, injection, and infusion services predominately involves affirmation of treatment plan and direct supervision of staff. These codes are not intended to be reported by the physician in the facility setting.

When these codes are reported by the facility, the following instructions apply. The initial code should be selected using a hierarchy whereby the chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration services. Infusions are primary to pushes, which are primary to injections. This hierarchy does not apply to physician coding.”
Emphasis added. Well, that settles that.


  1. Interesting. I work for two different ER groups, both of which are always hounding us on how to document for hydration so we get paid the maximum. Monthly notifications are sent out to the group on who missed what in documentation and IV infusions are a big one.

    Pulse ox is another one. The o2 sat may be on the chart but we need to make sure to document "normal" or "adequate for pt" next to it.

    Or document three findings on an xray interpretration to get paid - it is not good enough to say "negative for fx". We have to write "negative for fx., dislocation and STS" even though Rad interprets it again the next day and another bill will be generated.

  2. Actually glad to hear it. That is always my biggest missed charge on our monthly reports even though I try to do it.

    I though it would be fraud for the ER and radiologist to bill for an x-ray reading? Do payers track that? Who do they make the payment to and how is that decided?


  3. JB,

    Medicare and other payers will only pay for interpretive services for an X-ray once. There is no fraud per se if the radiologist also tries to bill, but it will probably get denied. The guidelines are very clear that the doc providing the interpretation contemporaneous to the patient care is entitled to bill for it.

    The reality is of course more complicated. Sometimes the first bill submitted is the one paid. Sometimes hospital politics preclude ER docs from billing for the interpretations. Often ER docs don't document the interp well enough to justify the charge. And in any case rads usually winds up over-reading it due to the hospital's compliance policies.


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