ED Coding and Reimbursement Alert

Question: A patient reported to the ED and received a level-two evaluation and management service. The patient file indicates that she is here due to effects from long-term current use of aspirin and steroids. How should I report the encounter if I want to note the steroid and aspirin use in the medical record?

Michigan Subscriber

Answer: You should report a pair of V codes in addition to the E/M code:
 
- report 99282 (Emergency department visit for the evaluation and management 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.

- attach ICD-9 code V58.65 (Long-term [current] use of steroids) to 99282 to represent the patient's steroid use.
 
- attach ICD-9 code V58.66 (Long-term [current] use of aspirin) to 99282 to represent the patient's aspirin use.
 
And you should report any specific signs or symptoms that prompted the visit.