ED Coding and Reimbursement Alert

Question: A patient with shortness of breath and heart palpitations presented to the ED after improperly ingesting her prescription medication. I know how to code the procedures, but I'm confused on how to incorporate E codes in this instance. Should I use them first or second? Maine Subscriber

Answer: E codes are supplemental codes that explain the circumstances of an accident, place of an accident or cause of injury and are never used as the primary diagnosis code. The primary diagnosis code should always be the reason for the service or procedure provided.

In your case, the presenting signs and symptoms of shortness of breath (786.05) and palpitations (785.1) support an EKG (93010, Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only), while ingestion of medications (e.g., 977.9, Poisoning by other and unspecified drugs and medicinal substances; unspecified drug or medicinal substance) supports a gastric lavage (91105, Gastric intubation). Remember that both procedures require thorough documentation. To identify this case correctly, you must list two separate E codes to explain the poisoning. Your first E code should identify the drug or chemical, taken from the table of drugs and chemicals in the ICD-9 manual. The second code should indicate the patient's condition resulting from the poisoning, e.g., coma or stupor. And the other E code will relate the cause of the poisoning as an accident, e.g., E858.3, Agents primarily affecting cardiovascular system. In poisoning cases, coders must also report the late effects, that is, the effects that continue after the acute phase of the reaction has passed. Because of the time and attention that must be given to poisoning cases, the level of E/M may justifiably be high (99284-99285, Emergency department visit for the evaluation and management of a patient ). Be sure to attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code and include documentation to prove that the service was significant and separately identifiable. Reader Questions and You Be the Coder were reviewed by Tracie Christian, CPC, CCS-P, director of coding for ProCode in Dallas.