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: