ED Coding and Reimbursement Alert

Question: If a patient presents in the ED with a minor laceration and no other injuries, but the physician documents an H&P that meets the requirements for an E/M code, can we charge for both the E/M and the repair?


New Jersey Subscriber


Answer: For you to report a separate E/M service, the service has to justify using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), which means it needs to be both separate and significant.
 
The service you describe was clearly separate, as evidenced by the questions the physician asked about the patient's medical history and his inspection of the wound. But think twice before you assume it was significant enough to warrant a distinct code.

Now that starred procedures are a thing of the past, laceration repair codes automatically include a brief E/M service. For example, if the context of the evaluation is straightforward and the exam entails only a cursory inspection of the wound (including the doctor's determination that it requires stitches), you may have difficulty reaching the payer's threshold for -significant- in the modifier 25 definition.

On the other hand, if the injury's context requires the physician to examine the patient for secondary problems, the service would meet the threshold for both separate and significant.

Examples of separate and significant:

- the patient falls on cement and lacerates his head; he feels dizzy
- the wound is deep or is bleeding more than expected for its anatomic site.

CPT states that the E/M subsequent to the decision for surgery is bundled, but implies that the E/M service prior to the decision for surgery is not bundled. For most payers, CPT principles would support the reporting of an E/M service.