ED Coding and Reimbursement Alert

Question: A patient presents to the ED complaining of a new painful mass on his left shoulder blade. During the course of a level-two E/M, the physician diagnoses a single carbuncle, which he then incises and drains. How should I code this scenario?

Maryland Subscriber

Answer: You should code separately for the E/M and I&D, but include the same diagnosis code for each CPT code. On the claim, report the following:

- 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) for the I&D of the carbuncle

- 680.3 (Carbuncle and furuncle; upper arm and forearm) linked to 10060 to represent the carbuncle

- 99282 (Emergency department visit for the E/M of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) for the E/M

- modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99282 to show that the E/M and I&D were separate services

- 680.3 linked to 99282 to represent the carbuncle.

Although CPT explicitly states that more than one diagnosis is not required to support both an E/M service and a procedure, many payers have edits that may result in denials when you use a single ICD-9 code. If you are unsure of the payer's policy, check your contract before filing an E/M and procedure with the same ICD-9 code.