ED Coding and Reimbursement Alert

Question: We had a patient present to the ED for a tetanus shot. Another physician had already examined her injury -- a thorn puncture. Our physician documented a very brief exam of the wound and ordered a tetanus shot. We generally code this evaluation and management (E/M) service as "low," but could this be a moderate-risk service, due to the intramuscular injection and the potential for adverse reaction?

Answer: If you refer to the "clinical examples" section of the CPT^® manual under code 99281 (Emergency department visit for the evaluation and management of a patient, which requires these three components: a problem focused history, a problem focused examination, straightforward medical decision making), one of the samples reads: "Emergency department visit for a patient for tetanus toxoid immunization." So while your assessment of the moderate risk associated with this scenario may be correct, you should continue to consider low-level E/M services for these situations usually 99281 if the patient has only a cursory interaction with the ED physician and has been pre- screened by another provider.

If the ED physician is seeing the patient for the first time, evaluating a traumatic injury, and addressing the mechanism and the potential complications, then a higher EM code would likely be appropriate.