ED Coding and Reimbursement Alert

Question: The physician diagnosed a patient with a second-degree burn on her right palm (944.25). He advised the patient to apply ice or run cold water over the area two or three times a day, but no specific care was given in the ED. In the documentation, he noted that blisters had formed over the base of the right thumb and palm that measured about 6 cm in diameter. How should I report this encounter?


Georgia Subscriber


Answer: Because the physician only evaluated the patient's problem and provided a treatment plan, you should report the appropriate emergency department evaluation and management code (99281-99285). 

The extent of the documentation that meets the three components - history, exam and medical decision-making - will determine the code level you choose. Depending on the scope of treatment, you can decide which of these codes is appropriate:
  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 - ... 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.