ED Coding and Reimbursement Alert

Question: If someone comes in with a fractured coccyx, should we enter the specific procedure code and the evaluation and management (E/M) code, or will the ICD-9 code and the E/M code suffice?

Roslyn Weinstein
Beth Israel Medical Center, New York

Answer: The CPT codes for outpatient encounters communicate the services provided to the patient, and the ICD-9 codes communicate the reason (i.e., medical necessity) the services were performed.

Under the ambulatory payment classifications (APCs), all provided services should be captured and reported with the appropriate CPT code for hospitals to receive full reimbursement. At the same time, to be in compliance, no CPT code should ever be reported unless the services represented by the code actually are performed and documented in the patients medical record.

In the example given, if a patient presents with a fractured coccyx, 805.6 (fracture of sacrum and coccyx, closed) would be reported as the diagnosis. The CPT code(s) reported would depend on the actual services rendered. For instance, if both an E/M service and closed treatment of the coccygeal fracture were separately performed and documented, both the E/M code with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and code 27200 could be reported. If no fracture treatment was provided, only the E/M visit code should be reported.

Source for the above Reader Questions is Laura Siniscalchi, RRA, CCA, CCS-P, CPC, education coordinator for Beth Israel Deaconess Medical Center in Boston.