ED Coding and Reimbursement Alert

Question: At 11 a.m. Wednesday, a patient reports to the ED complaining of lower back pain. Notes indicate that the physician performed a level-two observation service, during which she orders radiology tests, which come back showing lumbar spinal stenosis. A consultant performs an epidural steroid injection to alleviate the patient's pain.

On Thursday morning, the patient reports that the pain is under control. The patient is discharged at 1 p.m. Thursday. What codes should I report for this encounter?


Minnesota Subscriber

Answer: You can report codes for the observation and the injection. On the claim, report the following:

- 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epiduro-graphy], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) for the injection

-  99219 (Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the first day of observation

-  modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached to 99219 to show that the injection and the observation were separate services

-  724.02 (Spinal stenosis, lumbar region) linked to 62311 and 99219 to represent the patient's stenosis

-  724.2 (Lumbago) attached to 62311 and 99219 to represent the patient's back pain

-  99217 (Observation care discharge day management) for the discharge service on the second day of observation.