ED Coding and Reimbursement Alert

Be ready to scour notes for proof of separate E/M

All medical coders need to know the rules for coding an E/M service with modifier 25--but in the ED, that knowledge is put to use almost every time a patient enters the doors of the facility.

Remember, patients don't typically report to the ED at scheduled appointment times for preplanned procedures. Thus, you will often have to decide whether to include an E/M-25 on your procedure claims.

Coder input: -When a patient comes into the ED, for whatever reason, the physician must first evaluate the patient. The chief complaint (CC), review of systems (ROS), history and physical exam (PE) must be obtained to get a better understanding of the patient,- says Pamela Cline, RHIT, coder at Medical Account Services in Frederick, Md.

Often, the physician performs a significant, separate procedure after the E/M. In these situations, to show the separate nature of the services, you can report a procedure code and an E/M service appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). However, if you discover that the E/M was incidental to the procedure, you should report only the procedure code on the claim. (Less frequently, a patient will report to the ED and undergo a procedure, then report a totally separate complaint that requires an E/M service. In these instances, you can also report a procedure code and an E/M-25.)

Check Documentation for Separate E/M Evidence

So how can you tell if the physician performed a procedure and a separate E/M in the same encounter? It's all in the notes, experts say.

Carefully read the op report for -documentation of other body areas being examined, past medical history or other complaints documented,- says Sarah Luchard, CPC, coding supervisor at Practice Management Associates in Williamsburg, Va. If you see any of these elements in a procedure report, you may be able to file a separate E/M-25.

Remember: A different diagnosis is not necessarily required for reporting a procedure and an E/M-25 on the same date. Often, the same injury or illness will prompt the E/M service and the procedure.

Consider this example from Cline. A patient comes in with a bump on his leg. He says the wound site is painful, red and sore. The physician documents the CC, reviews medical history with the patient and performs an ROS to check for any trauma to other systems.

Then she performs a PE, diagnoses an abscess and decides to perform an incision and drainage (I&D) on the patient to drain the wound, relieve pain and obtain cultures. The physician discharges the patient with prescribed antibiotics, and schedules him for a wound check in seven days.

Because the physician decided to perform the I&D after a thorough E/M during which she checked other systems, you can report a procedure and an E/M code. On the claim, report the following:

- 10060 (Incision and drainage of abscess [e.g. carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) for the I&D

- the appropriate-level E/M code (such as 99282, Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) based on the physician documentation.

- modifier 25 appended to the E/M code to show that the service was separate from the I&D

- 682.6 (Other cellulitis and abscess; leg, except foot) linked to 10060 and the E/M code to prove medical necessity for both services.

 Also, take this advice from Cline to heart when filing: -When billing for an E/M with modifier 25, the [separate] chief complaint/history of present illness and physical exam must be documented,- she says. If not, you cannot charge for a separate E/M. -Reading through the medical record is where we, as coders, need to abstract the information needed- for successful modifier 25 claims, she says.