ED Coding and Reimbursement Alert

Question: A patient reports to the ED with a cut in the vestibule of the mouth; it is bleeding moderately. The patient reports that he bit down on a lobster shell by mistake and cut the roof of his mouth. After stopping the bleeding, the ED physician irrigates the area to ensure there is no debris. Then, she uses sutures to close a 2.2 cm wound. Notes indicate a level-three E/M preceded the repair. I reported 40831 and received a denial. What happened?

California Subscriber

Answer: The claim didn't fly because the wound was not long or complicated enough to justify your code choice. When you resubmit the claim, report the following:

• 40830 (Closure of laceration; vestibule of mouth; 2.5 cm or less) for the mouth repair

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and 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 99283 to show that it was a separate service from the repair

• 873.65 (Open wound of head; internal structures of mouth, without mention of complication; palate) appended to 40830 and 99283 to represent the patient's injury.

Explanation: In order to report 40831 (... over 2.5 cm or complex), the wound must exceed 2.5 cm or the closure must be complicated. The use of irrigation does not up the complexity of this procedure to the level of 40831. If the vestibule had suffered extensive tissue damage, crushing, or required complex closure (such as retention sutures), then you may have been able to report 40831.