ED Coding and Reimbursement Alert

Question: A patient is brought to the ED via ambulance with acute myocardial infarction (AMI). The ED physician talks to the emergency medical technician (EMT), who reports that the patient "flat-out refused" any aspirin, but the patient could not catch his breath enough to tell the EMT why he didn't want aspirin (There were no caretakers or relatives at home when the AMI occurred, so the patient is in the ambulance alone). During the history portion of the E/M, the patient's medical record reveals he is severely allergic to aspirin. We are reporting on measure 28 for the Physician Quality Reporting Initiative (PQRI). Which PQRI code and P modifier should I use for this encounter?

Answer: Use the modifier that reflects the patient's allergy as the reason for not meeting measure 28 (Aspirin at arrival for acute myocardial infarction [AMI]). On the claim, report the following to satisfy the PQRI measure:

4084F (Aspirin received within 24 hours before emergency department arrival or during emergency department stay [E/M])

Modifier 1P (Performance measure exclusion modifier due to medical reasons) appended to 4084F to explain why the patient did not receive aspirin.

What about 2P? While the initial reason for the aspirin refusal was patient refusal, you should choose modifier 1P over 2P (Performance measure exclusion modifier due to patient reasons) in this scenario. The descriptor beneath modifier 1P reads: "Reasons include:

contraindicated (patient allergic history, potential adverse drug interaction, other) other medical reasons."