ED Coding and Reimbursement Alert

Question: A 26-year-old patient who is 24 weeks pregnant presents to the ED; “I been throwing up constantly for three days, she tells the nonphysician practitioner (NPP). During a level-four E/M service, the physician discovers that the patient is also experiencing abdominal cramping, but no diarrhea or fever. 

He performed a limited transabdominal ultrasound to check on the fetus, which shows no signs of complications due to the mother’s condition. 

The ED physician discharges the patient with prescriptions, and instructions to report to the obstetrician if her vomiting has not abated within two days. Final diagnosis was “hyperemesis gravidarum w/metabolic disturbance. No dehydration.” How should I code this scenario? 

North Carolina Subscriber

Answer: You can code the E/M and ultrasound separately, but you’ll need to stick a modifier on each code in order to report the encounter successfully.  Assuming a good ultrasound procedure note was included, on the claim, report the following:

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; 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 US were separate services
• 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited [e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], 1 or more fetuses) for the ultrasound
• Modifier 26 (Professional component) appended to 76815 to show that you are only coding for the physician’s interpretation and report of the ultrasound (the facility will bill for the use of the ultrasound equipment)
• 643.13 (Hyperemesis gravidarum with metabolic disturbance; antepartum) appended to 76815 and 99284 to represent the patient’s hyperemesis and current episode of care.