READER QUESTIONS:
All Patients Are New to ED
Published on Wed May 04, 2005
Question: A patient presented to the ED with a 2-cm uncomplicated laceration to the hand. The physician repaired the laceration and sent the patient on his way. Is it appropriate to code just the procedure, or should I also report an E/M service?
Washington Subscriber
Answer: Usually, because the emergency department physician must assess the extent of the patient's injury before treating it, you will report both the procedure code and the appropriate evaluation and management code.
Most of the time - especially in the ED, where every patient is new - the physician needs to obtain a history and understand the context of the injury or illness. This may involve ordering tests, such as x-rays, or prescribing medication.
While there are certainly cases in which the doctor has provided minimal documentation of the history and exam, which would preclude you from separately reporting an E/M service, most of the time that won't be the case. For the E/M service, you'll report one of the following codes:
99281 - Emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making
99282 - ...an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity
99283 - ...an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity
99284 - ...a detailed history, a detailed examination, and medical decision-making of moderate complexity
99285 - Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity.
