ED Coding and Reimbursement Alert

Certain E/M services are built in to procedure codes

When a patient reports to the ED for treatment of a specific injury or illness, the physician usually performs some evaluation and management service along with the procedure.
 
Issues: What E/M services are bundled into the procedure code, and how can you tell whether an encounter involved enough service to report a separate E/M?
 
If you can't answer these questions, you won't know whether it is possible to report a separate E/M with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in addition to the procedure code.

Identify Procedures With Inherent E/Ms

According to experts, your physician will provide certain services that are components of the procedure code and cannot be reported as separate E/Ms.
 
-If a patient came in for a laceration repair, the physician is not going to just jump right in and start suturing. She is going to first talk about how the injury occurred, assess the wound and decide what suture material to use, etc.,- says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, coding analyst for CodeRyte Inc., national speaker, teacher of coding review courses, and former AAPC National Advisory Board member.
 
Some ED patients, such as accident victims, will always require significantly separate E/M before the physician can decide how to proceed -- such as a car crash victim with multiple lacerations, possible broken bones, and a potential concussion.
 
When the physician's E/M service extends past the chief complaint for the injury, you may be able to report it separately -- if you can prove the physician provided a separate E/M, -something more than the minor E/M that is included with the procedure,- says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, of CRN Healthcare Solutions in Tinton Falls, N.J. The physician might also provide a separate E/M when a patient reports for a procedure or service, then reports a totally separate complaint during the encounter.
 
Separate E/M almost a given: In the ED, physicians will almost universally provide a separate E/M, according to CPT rules. Based on federal mandate, all patients presenting to the ED need to have some type of evaluation to rule out an emergency medical condition under EMTALA. Just make sure the chart reflects these components and you will have likely satisfied the documentation requirements for a separate E/M service.
 
Both CPT and CMS agree that a separate diagnosis is not required to justify a separate E/M service. However, commonly used payer edits will make your claims processing a bit easier if each reported CPT code has a corresponding unique ICD-9 code.

Try Singing the -HEM Song-

Deciding whether your physician has provided a separate E/M in addition to a distinct procedure is somewhat difficult, but Jandroep has developed a little trick that she relays to coders.
 
-I teach a little rhyme that seems to help people remember: -If you don't have a HEM, you can't bill an E/M,- - she says.
 
Of course, the letters in HEM stand for -History,- -Exam,- and -MDM,- the three key components of E/M services. -If you can't see those three components separate from the procedure note, you most likely don't have a separately billable E/M service,- Jandroep says.
 
Consider this encounter, in which an ED physician performs a procedure and also provides a significant, separately identifiable E/M:
 
A 13-year-old patient reports to the ED with a 3-cm laceration on his forehead above the left eye and a sore left shoulder, the result of running straight into a goal post during a soccer game. The physician documents the appropriate history, examines the head wound and performs a neurologic exam related to that injury. She also examines the patient's shoulder area for a possible fracture or dislocation.
 
On the claim,

 - report the laceration repair using 12013 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucus membranes; 2.6 to 5.0 cm).

 - attach 873.42 (Open wound of face without mention of complication; forehead) to 12013 to account for the forehead wound.

 - report the appropriate E/M code. In this case, it would probably be 99283 (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 moderate complexity), but it could be higher depending on the severity of the head injury.

 - attach modifier 25 to the E/M code to show that the physician performed two significant, separate procedures.

 - attach 959.2 (Injury; shoulder and upper arm) to the E/M code to account for the patient's sore shoulder.

Remember: If the physician finds more extensive shoulder or head damage, be sure to use the most specific diagnosis codes possible.
 
Note: For information on changes concerning modifier 25 use, see -Use Transmittal to Check on Modifier 25 Changes- at left.