ED Coding and Reimbursement Alert

Question: Our office is currently engaged in a debate regarding the appropriate coding for a patient returning to the emergency department (ED) for a repeat rabies vaccination following an encounter with a bat. The patient had initially received post-exposure prophylaxis rabies vaccinations during their first ED visit and is now back for the next injection in the series.

There are three differing viewpoints within our office on this matter:

• Camp A believes that an evaluation and management (E/M) service should not be coded for the return visits as the injection was originally ordered during the first ED visit.
• Camp B supports reporting an E/M code for the ED physician, specifically suggesting code 99282), citing minimal COPA and risk factors.
• On the other hand, Camp C, the treating physician, strongly disagrees with Camp A and challenges Camp B's assessment. They argue that the patient's condition warrants a low to moderate level of COPA due to the patient's exposure to a potentially fatal condition like rabies. Additionally, they believe that the decision to administer the rabies vaccination constitutes at least a low-risk management decision, advocating for coding the visit as 99283

We would appreciate an expert opinion to help resolve this debate and determine the most appropriate coding for this scenario.

AAPC Forum Subscriber

Answer: The initial issue is straightforward, as these return visits are billable. In the case of a repeat visit, the ED physician must conduct an evaluation to look for any signs or symptoms related to the initial exposure and assess the patient for any adverse reactions to the previous vaccine. Therefore, the ED physician service should have an E/M code assigned.

Determining the appropriate level of service involves considering factors that impact the complexity of medical decision making (MDM):

• Presenting complaint: The fact that the patient was bitten by a bat and is returning for a rabies vaccination indicates a potentially serious health concern that requires ongoing monitoring and treatment.
• Need for ongoing management: Rabies is a serious viral infection that can be fatal if not treated promptly. The physician would need to assess the patient's response to the initial vaccination, any signs of infection, and the need for further vaccinations and monitoring.
• Risk of complications: Rabies vaccinations can lead to side effects, so the physician must assess the risk of adverse reactions and provide appropriate counseling and management.

Proper evaluation of this patient involves continuous monitoring and management of a potentially severe medical condition, including additional vaccinations and monitoring for complications.

Based on these considerations, the MDM for the ED physician in such a case would typically be classified as at least low complexity for a patient without current signs or symptoms, supporting an ED E/M code of 99283 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making). However, if signs or symptoms of illness or adverse effects are detected during the evaluation, the MDM complexity and the resulting E/M code would likely increase.

Remember: The rabies vaccine is considered prescription drug management, and not separately codable.

Todd Thomas, CPC, CCS-P, President, ERcoder, Inc.