ED Coding and Reimbursement Alert

A patient reports to the ED with a cut on their right thumb. They were using a knife to cut an apple when it slipped and sliced into their right thumb. The physician performs an ED evaluation and management (E/M) service to assess the severity of the injury. The laceration is clean, straight, and shallow, but it still requires closure along with Lidocaine for the repair and prescription meds for pain control. Notes indicate that the physician provided moderate-level medical decision making (MDM) during the E/M.

They then perform closure that does not require debridement or decontamination.

Scenario 2

From Corrie Alvarez, CPC, CPC-I, CEDC, CPMA, CEMC, CRC, CPCO:

A 30-year-old patient slipped and fell while tap dancing, sustaining the following lacerations:

• 2.0 cm laceration on forehead
• 2.5 cm laceration on scalp
• 1.5 cm laceration on right forearm
• 1.5 cm laceration on right foot
• 3.0 cm laceration on lower left leg requiring layered closure
• 1.5 cm laceration on chin requiring layered closure

ANSWERS

Scenario 1

On the claim, you’d report:

• 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less) for the wound repair
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99284 to show that a significant, separately identifiable E/M led to the decision for wound repair
• S61.011A (Laceration without foreign body of right thumb without damage to nail, initial encounter) appended to 12001 and 99284 to represent the patient’s injury
• Y93.G1 (Activity, food preparation and clean up) appended to 12001 and 99284 to represent the cause of the patient’s injury

Coding Scenario 2

On the claim, you’d report:

• 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) for the forehead repair
• 12051 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) for the chin repair
• S01.81XA (Laceration without foreign body of other part of head, initial encounter) appended to 12011 to represent the patient’s injuries to the forehead and chin
• 12032 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm) for the left leg repair
• Modifier LT (Left side) appended to 12032 to indicate laterality
• S81.812A (Laceration without foreign body, left lower leg, initial encounter) appended to 12032 to represent the patient’s injury
• 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm) for the scalp, right forearm, and right foot repairs
• Modifier RT (Right side) appended to 12002 to indicate laterality
• S01.01XA (Laceration without foreign body of scalp, initial encounter) appended to 12051 to represent the patient’s injury
• S01.01XA, S51.811A (Laceration without foreign body of right forearm, initial encounter), and S91.311A (Laceration without foreign body, right foot, initial encounter) appended to 12002 to represent the patient’s injuries
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99284 to show that a significant, separately identifiable E/M led to the decision for multiple wound repairs

Modifier alert: Remember to append modifier 59 (Distinct procedural service) to 12051, 12002, and 12011 to show that these repairs were distinct and separate from the primary repair (12032).

1 more Dx: Also, be sure to append Y93.41 (Activity, dancing) to 12032, 12051, 12002, and 12011 to represent the cause of the patient’s injuries.