1. As an outpatient hospital facility, how would we most accurately code our emergency department and clinic visits?
There are two types of emergency departments:
Type A - available 24/7
Visits to a Type A emergency department are billed with 99281-99285
Type B - dedicated emergency department
Visits to a Type B emergency department are billed with G0380-G0384
Hospital outpatient clinic visits for assessment and management are billed with G0463.
For a list of condition codes, occurrence codes, occurrence span codes, value codes, revenue codes and all other required data reported on the UB-04, please visit the NUBC
website for the official UB-04 data specifications manual.
2. When is it appropriate to append modifier 25 to an E/M code?
Append modifier 25 to a separately identifiable E/M service provided on the same day as a diagnostic and /or therapeutic procedure.
Example: A patient reports for pulmonary function testing in the morning and attends the hypertension clinic in the afternoon. Report modifier 25 with the E/M code for the hypertension clinic visit to indicate a separately identifiable service provided on the same date as the pulmonary function testing. This allows reimbursement for both services.
3. When we do pulmonary function testing, there is a significant amount of time spent educating the patient, preparing the patient, etc. Would it be appropriate to bill an E/M code to cover the costs associated with the testing?
Routine care associated with diagnostic or therapeutic procedures, (such as education, preparation, and on-going nursing care) is included in the reimbursement associated with the procedure code for the testing. It is not appropriate to bill an outpatient clinic visit code for routine care associated with a diagnostic or therapeutic procedure.
4. Our outpatient department provides services such as audiology testing, IV administration of medications and radiology procedures. These services require additional time and resources for monitoring vital signs, re-assessments, patient education and preparation, and extensive documentation. Is it appropriate to bill a low-level E/M code to cover the cost of these services?
No. These are routine care expected when administering the diagnostic test or procedure, and therefore, the cost would be included in the procedure code used for the service. For example, if the patient receives IV chemotherapy, it is standard to monitor vital signs, re-assess and provide education. Therefore, it would be inappropriate to bill for these services separately with an outpatient clinic visit code.