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Reimbursement Advisor

Labor triage: Not an ER service

February 2004 · Vol. 16, No. 2

<huc>Q</huc> Some pregnant patients (trauma cases, etc) go through our hospital emergency room (ER), but most go to our labor and delivery triage center, which is staffed by residents 24 hours a day, with an in-house attending always available. Some universities I know use ER codes for triage-center billing, because they feel it meets the requirements of an ER. Is this acceptable?

<huc>A</huc> No. Both Medicare and CPT guidelines state that to use the ER services codes, you must provide the service in the hospital’s designated emergency room or department. The emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. Within this definition, there is the tacit understanding that such care must be provided to all, without discrimination as to gender or age. You have stated that your hospital has a designated ER; thus, the emergency services codes (99281-99285) are appropriate only when care is provided in that setting.

If physicians in the labor and delivery center are seeing pregnant patients for triage, your coding choices are:

  • observation care admission (99218-99220),
  • observation care discharge (99217),
  • same-day observation admission and discharge (99234-99236),
  • outpatient care (99201-99215), or
  • outpatient consultations (99241-99245).

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

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