ED Coding and Reimbursement Alert

Question: A father brings his 2-year-old son into the ED with an injury to his right ear; the boy was scratching and pulling at the ear, which appeared swollen and red. The ED physician performs a level-two E/M, during which she visualizes a foreign body in the external ear canal. The physician then performs irrigation to flush out the object (no mention of anesthesia in notes). A small pebble was removed of the type found on the playground at the child’s daycare center. Can I code the procedure separately, or is it considered part of the E/M?

Massachusetts Subscriber

Answer: Based on your description, you should be able to report an E/M and a procedure code for this scenario. This scenario would justify a low-level E/M such as 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity) and code 69200 (Removal foreign body from external auditory canal; without general anesthesia) for the foreign body removal from the ear. As long as the documentation supports both the procedure and the E/M code you should be okay reporting both.