ED Coding and Reimbursement Alert

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: