ED Coding and Reimbursement Alert

The You Be the Coder answer in the December ED Coding Alert, page 93, needs to be clarified.

Not every laceration repair performed in the ED and billed to the carrier qualifies to include an evaluation and management (E/M) service. The deciding factor is if there is adequate documentation to support something beyond the performance of the repair itself.

CPT notes that with minor starred procedures, the pre- and postcare are not included in the procedure, so an E/M level would seem to be appropriate in these cases. However, if all the provider documents in the chart is the procedure and not any history and exam, it is questionable if that meets the criteria for an E/M level in addition to the procedure code.

To justify submitting an E/M service for a laceration repair to Medicare, the documentation must support a significant, separately identifiable service. This may be the case, for instance, when a patient falls and has a head laceration, and the physician must determine whether a closed head injury was sustained, or when the patient has other injuries or problems that require a lot of evaluation. But there are other times when the injury is straightforward and the doctor evaluates the laceration for foreign body, verifies the immunization status and then cleans and repairs the wound. These are considered standard steps in wound care and do not justify the use of a separate E/M service.