ED Coding and Reimbursement Alert

Question: A 94-year-old nursing home patient arrives to the ED via ambulance after her gastrostomy tube fell out; the emergency medical technician (EMT) informs the physician that the patient has been complaining of extreme thirst. During the examination, the physician diagnoses dehydration, and discovers the patient has missed several doses of antibiotics for a urinary tract infection (UTI). The physician orders labs, conducts a 34-minute intravenous rehydration, administers the necessary antibiotics, and evaluates the G tube site; notes indicate a level-four E/M. Then, she replaces the patient's G tube (no mention of imaging or guidance). Can I report the hydration separately for this patient?

Minnesota Subscriber

Answer: The hydration service is not reportable on the professional side in the ED. On the claim, report the following:

• 43760 (Change of gastrostomy tube, percutaneous, without endoscopic imaging or endoscopic guidance) for the G tube replacement
• V55.1 (Attention to artificial openings; gastrostomy) appended to 43760 to represent the patient's G tube malfunction
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity ...) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service on the by the same physician on the same day of the procedure or other service) appended to 99284 to show that the E/M and G tube replacement were separate services
• V55.1 appended to 99284 to represent the patient's G tube malfunction
• 276.51 (Dehydration) appended to 99284 to represent the patient's dehydration
• 599.0 (Urinary tract infection; unspecified) appended to 99284 to represent the patient's UTI.

ED is hydration exception: Remember that physicians cannot report 96360 (Intravenous infusion, hydration; initial, 31 minutes to 1 hour) or +96361 (... each additional hour [List separately in addition to code for primary procedure]) in a facility setting. When the ED physician performs hydration services, the insurer considers it part of the E/M.