ED Coding and Reimbursement Alert

Question: One of our nurses claims I can't use an E/M service code with procedure codes, e.g., 46754 (Removal of Thiersch wire or suture, anal canal). She uses the E/M code only and writes off the repair.

But an article in the August 2002 issue of ED Coding Alert states that facilities are allowed to claim with separate codes for E/M services and procedure services, if appropriate. How should I respond to the nurse's advice?

Oregon Subscriber

Answer: Your nurse is coding incorrectly. Let her know that by routinely writing off procedure codes and billing only for E/M, she's deviating from both CPT and Medicare guidelines. According to CPT guidelines, codes for starred (*) procedures, which include most lacerations, cover only the procedure. Any additional evaluation for injury, mechanism, or medical comorbidities counts as extra physician work, recognized by the 9928X series of E/M codes (emergency department services codes).

For coding nonstarred procedures that qualify as "major" (defined by Medicare as those with a 90-day global fee period), you can report an E/M code with modifier -57 (Decision for surgery). Given the severity of the presented illness or injury, a decision to perform a major procedure requires significant physician work.

For all other nonstarred procedures, documentation must justify the medical necessity of coding a separate E/M code for services such as screening for injuries, advancing infection, or systematic illness. If you code an E/M service in addition to a nonmajor procedure code, remember to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Reader Questions and You be the Coder were reviewed by Michael Granovsky, MD, CPC, CFO, of Greater Washington Emergency Physicians in suburban Maryland.