ED Coding and Reimbursement Alert

Question: If a patient presents in the ED for a gastro tube change, can I bill the tube change (43760) and an emergency department E/M service (99281-99285)?

Louisiana Subscriber

Answer: You can charge an E/M when your physician performs a separately identifiable service from the other procedure codes. According to CPT, 43760* (Change of gastrostomy tube) is a starred, or minor, procedure. When the star follows a code, the service listed includes the surgical procedure only. This means payers that follow the starred/non-starred guidelines will pay you for services that represent any pre- and postoperative services for the procedure, including an E/M service. You should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service when reporting with a starred code.
 
Medicare, however, is the payer for many of the patients an ED physician treats, and it does not follow the starred/non-starred distinction. Medicare instead assigns global periods to codes that include any E/M work related to the procedure. When reporting to the carrier, therefore, you should substantiate a separate E/M service for minor procedures because their global packages include 10 days of care. Examples of separate services include when documentation indicates that a patient has fever, lab work, a urinalysis and chest x-ray (from the 71010-71555 series); when documentation describes a patient as dehydrated (for example, 276.5), and the physician ordered lab work and IV administration.
 
To read more on global packages, refer to "The Global Surgical Package Unwrapped" in the February 2003 ED Coding Alert.

  You Be the Coder and Reader Questions reviewed by Mike Granovsky, MD, CPC, CFO.