ED Coding and Reimbursement Alert

Question: A patient presented to the emergency department for a second shot in a series of three shots for rabies. Should I report these as low-level evaluation and management services (with code 99281), or can I use 99283 if all criteria are met?

Pennsylvania Subscriber

Answer: Ultimately, you should report the E/M code justified by the physician's chart documentation.

While Appendix C in the CPT book describes a visit for a patient for tetanus toxoid immunization under 99281 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making), in truth, the patient may not require an evaluation and management service at all, depending on how much pre-shot work the physician actually had to perform.

You should probably not report 99283 (... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity), because it's unlikely that a patient presenting for rabies shots meets all the necessary criteria. Billing for a low-level E/M service, though, may be appropriate, especially if the patient has not been to the same emergency department for the first two shots.