ED Coding and Reimbursement Alert

Typically, these encounters involve moderate MDM

When the ED physician performs an injection, infusion or hydration, look for evidence of a separate evaluation and management service on the op report to secure all of your deserved reimbursement on these claims

Why? -Anytime a separately identifiable and significant E/M service is provided, you can charge for both the E/M and the injection/infusion/hydration codes,- says Kevin Arnold, CPC, a coding instructor with Health Information Services Outpatient Coding in Danbury, Conn. -In the ED, separate E/M services are very common with the injection/infusion/hydration codes. It would be rare not to have both.-
 
Modifier 25 Makes Claim Legitimate

But to get E/M payment, you-ll need a hand from modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Michael Granovsky, MD, CPC, FACEP, vice president of MRSI, an ED billing company in Stoneham, Mass.

Example: A 44-pound 5-year-old with vomiting and diarrhea presents with signs of moderate dehydration. The ED physician discusses with the parents the role of IV fluids rather than an attempt at oral rehydration. An IV is initiated, and a 400-ml bolus of normal saline is provided over one hour. The child's condition then stabilizes.

During the hydration, the physician is immediately available for any issues and is in contact with and supervising the nursing staff. The physician reassesses the child after the hydration and initiates a trial of oral fluids.

In this case, you would:

- report 90760 (Intravenous infusion, hydration; initial, up to one hour) for the hydration.

- report the appropriate E/M service, in this case probably 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity).

- attach modifier 25 to the E/M service to show that it was significant and separate from the hydration.

- attach ICD-9 code 276.51 (Dehydration) to 90760 to show the reason for the hydration service

- attach ICD-9 codes 787.03 (Vomiting alone) and 787.91 (Diarrhea) to 99284 to support the E/M service and demonstrate the overall medical necessity.

Watch for Moderate MDM

When you see a patient for a separate E/M service during the same encounter as an injection/infusion/ hydration, you have no specific limit on the level of service you can report, Granovsky says. However, you have to make sure that the physician's actions, as reflected in the medical record, justify your level of service.

-Usually the nature of the presenting problem that requires infusion or injection will coincide with at least moderate medical decision-making,- Granovsky says. That means that most infusion/injection/hydration sessions will support a level-three (99283) or level-four (99284) E/M service, and perhaps even higher.

Exception: If a patient reports to the ED and the physician discovers that the patient requires a simple injection, such as a tetanus injection, the visit is likely a level-one service (99281), according to CPT 2006.