ED Coding and Reimbursement Alert

Question: A father brought his son to the emergency department for a swollen finger that had pus draining from the puncture site. The ED physician's examination revealed swelling along the radial aspect of the index fingernail fold into the base of the nail. The volar pad was soft, with no swelling or inflammation proximal to the DIP joint. The physician prepped the finger and made a 7-mm incision to drain the pus. The wound was then irrigated and a small amount of packing placed in it. The physician did not remove the nail. The physician also started the patient on antibiotics.

The exam seemed to pertain only to the finger. Should I apply the level-V emergency department services code (99285), appended by modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of other service) along with 10060* (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) appended by modifier -52 (Reduced services)?

Florida Subscriber

Answer: When an ED physician performs a straightforward drainage of a paronychia, you should code with 10060. Remember that a starred (*) procedure code covers only the procedure. You should be able to code separately for a medically necessary E/M code. To be safe, include documentation that indicates additional exam components or screening for advancing or systemic infection. In your case, documentation probably indicates that the physician separately examined the finger and arms for signs of lymphangitis, cellulites, tenosynovitis, and perhaps even osteomyelitis above and beyond the drainage of the paronychia.

In addition, your physician wrote an Rx for antibiotics. As long as the physician documented these findings, you should be clear to code for an E/M service appended with modifier -25. If no Rx was given, then you could apply 99282, the level-two emergency department E/M services code and append it with modifier -25, if you fulfilled documentation requirements.

In your example, the physician also treated a large collection of pus that required a 7-mm incision and packing. Usually a paronychia requires no more than a few millimeters of incision and no packing. You could try coding for the more complicated procedure using 10061 (... complicated or multiple). If you use 10061 instead, note that the rules change. For a nonstarred procedure code, if you add an E/M code you must submit a more thorough set of documentation. Sufficient documentation usually includes a thorough evaluation for advancing localized infection or systemic infection, and sometimes even an evaluation of an unrelated complaint.

Do not apply modifier -54 (Surgical care only) to either 10061 or 10060. Follow-up work for these procedures is usually not required.

In your case, the little boy is clearly not a Medicare beneficiary. But if a similar situation occurred with a Medicare patient, and he did return within 10 days for a related complaint or complication, you should not use a second E/M service code. Ten days is the global fee period for those procedures.