ED Coding and Reimbursement Alert

An experienced ED physician explained it this way to Gregg Glinka, RN, vice president of CPR Charges at M. Leco and Associates, a healthcare consulting business in Pittsburgh. If a patient comes to the ED for a simple laceration repair (12001) and that is the only reason for seeking medical attention, an E/M may be "inappropriate" to report because "there is no separately identifiable reason to charge an E/M plus the procedure code." If, however, the patient had a syncopal episode and a simple laceration, "that scenario would indicate a separately identifiable reason for the E/M (syncope)." In this case, modifier -25 is appropriate, but adding the modifier to an E/M for a minor procedure is "incorrect."

Whether you code the E/M service in addition to the starred procedure is a matter of interpretation, Glinka argues, but he is conservative about reporting it routinely.

Gilhooly adds another example that warrants using an E/M code: An elderly patient presents with a laceration as a result of cutting her finger when chopping meat for dinner. This patient has the potential of other risk factors, so the ED physician performs an E/M to find out, for example, what medications the patient is on, such as a blood thinner, which could affect how the physician treats the wound. If the patient is diabetic, there's an added concern for bacterial infection, and the physician discovers all of this in an E/M assessment. Here you would assign the E/M code in addition to the simple laceration repair.

For Medicare patients, you should generally not code an E/M when the physician is just examining and repairing a laceration. Medicare doesn't recognize the starred (*) procedure concept. Instead, Medicare groups procedures according to the global surgical package, which is identified as minor (post-op period 0-10 days) or major (0-90 days). For Medicare minor procedures, you should have a separately identifiable E/M service to bill it in addition to the simple laceration repair. Medicare's definition of global surgical packages makes this guideline clear, Gilhooly adds. (You can find that definition at http://cms.hhs.gov/manuals/14_car/3b4820.asp.)

But there are exceptions. If the laceration is of the scalp, for example, which was the result of a syncopal episode and a fall, you could get paid for the necessary workup for the cause of the syncope, she states. The justification is that your physician needed to evaluate the patient for syncope.

Here's another Medicare hint. Use the same diagnoses code for the procedure and the E/M services when the single diagnosis code best explains the E/M, Gilhooly says. If you're hunting down second diagnoses codes for the E/M code, you may want to reconsider. A common "urban myth" for Medicare coding is that you need to have a second diagnosis code to justify reporting an E/M separately, Gilhooly states. The second diagnosis code may make the E/M "clear," she says, but in 1993, CMS, then the Health Care Financing Administration, sent a letter to carriers debunking the myth regarding second diagnosis requirements. The letter supports that Medicare does not require a separate diagnosis for the E/M code reported with a simple laceration repair and that Medicare is following the CPT rules for significant and separate E/M codes, which does not imply that you need two diagnoses codes, Gilhooly insists.

You can also use this rule of thumb for Blue Cross Blue Shield, which recently changed its policy on requiring a second diagnosis, La Fleur says.

As a final piece of advice for all payers, do not use 99025 to represent the evaluation of the patient unless specifically requested by the carrier, La Fleur says. Code 99025 is usually not the preferred code for any session, he says. Use an appropriate E/M code with a modifier.