ED Coding and Reimbursement Alert

Question: The ED physician performs a level-four E/M service for a patient and diagnoses a peritonsillar abscess. Notes indicate that the physician aspirates the abscess to confirm the presence of pus and then incised and drained. How should I code this encounter?

Minnesota Subscriber

Answer: For this encounter you would report

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: detailed history; a detailed examination; and medical decision making of moderate complexity ...) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 to show that the E/M and aspiration were separate services
• 42700 (Incision and drainage abscess; peritonsillar)
• 475 (Peritonsillar abscess) appended to 42700 and 99284 to represent the patient’s abscess.

ICD-10 code

J36 (Peritonsillar abscess)