ED Coding and Reimbursement Alert

Question: If a patient presents to the ED for just a tetanus shot, can you also report an E/M service? The chart documentation shows a very brief exam of the wound and the physician 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?

Texas Subscriber

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 if the patient has only a cursory interaction with the ED physician.

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 as the Tetanus shot does represent prescription drug management in the risk table.