ED Coding and Reimbursement Alert

Question: The ED physician performs simple repair on a 4.6-cm laceration on a patient's right shoulder. Two days later, the patient returns complaining that his wound is inflamed and painful. The physician finds an infection in the patient's shoulder, and treats the wound with antibiotics. Can we charge a patient visit in this scenario?

Kentucky Subscriber

Answer: Because the second visit happened during the global period of the laceration repair (12002, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.6 cm to 7.5 cm), the answer will depend on the patient's insurer. If a patient presents during the global period of a surgical procedure due to an adverse reaction stemming from that procedure, Medicare bundles the visit into the global surgical package.

In your scenario, the operative site was infected, so Medicare would consider this an adverse reaction to the earlier procedure. If the patient has Medicare insurance, do not report the visit.

However, CPT's rules are a bit different. It only bundles visits that are typical, uncomplicated follow-up care; adverse reactions are not part of the global package. If you-re sending the claim to an insurer that follows CPT rules, you may be able to code the second visit with the appropriate-level E/M code.

So if the notes indicate that the ED physician performed a level-two E/M to address the shoulder infection, you can report 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) to payers that follow CPT rules.

Best bet: CPT-observing payers may have differing views on what constitutes -adverse reaction.- Play it safe by checking with your payer before coding any visit during a global surgical period.