ED Coding and Reimbursement Alert

Question: A patient with carpal tunnel syndrome (CTS) in her right wrist reports to the ED; she says even though she has kept the wrist in a short splint and attended physical therapy, it still "hurts bad" -- specifically that her hand is tingling, her wrist hurts constantly, and she has trouble using her fingers. After performing a problem focused history and an expanded problem focused exam, the ED physician decides to perform a carpal tunnel injection (CTI). He injects 40 mg of Depo-Medrol, puts the wrist back in the splint and sends the patient home. How do I code this encounter? Is there enough evidence for a separate E/M service?

Minnesota Subscriber

Answer: You should go back and check the encounter specifics to be sure, but it sounds as though the ED physician provided a low-level E/M before the CTI.

On the claim, report the following:

- 20526 (Injection, therapeutic [e.g., local anesthetic, corticosteroid], carpal tunnel) for the CTI

- 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a problem focused history; a problem focused examination; and straightforward medical decision making ...) 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 99281 to show that the E/M and injection were separate services

- 354.0 (Carpal tunnel syndrome) appended to 20526 and 99281 to represent the patient's condition.

Explanation: You mentioned that the physician performed an expanded problem focused exam and focused history. Also, the physician's decision to perform the CTI was a straightforward medical decision. Based on this information, you would choose 99281 for the E/M.