ED Coding and Reimbursement Alert

Question: A 27-year-old pregnant patient reports to the ED after an accident: she fell down the stairs at her workplace, and is complaining of right wrist pain. The ED physician provides a level-three E/M, during which she diagnoses and wraps a sprained right wrist ligament; then, she performs obstetrical ultrasound (US). After examining the US, the physician determines that the fetus has not sustained any injury. The notes show the physician felt the injury did not have any effect on the fetus. How should I code this encounter? Do I need a modifier?

Florida Subscriber

Answer: Youll need two modifiers: one to separate the E/M and the US, and another to specify the physicians role in the US treatment. You should also go back and check the notes to see how far along the woman was, as this will affect US code choice.

On the claim, report the following:

" 76801 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester [< 14 weeks 0 days], transabdominal approach; single or first gestation) or 76805 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester [> or = 14 weeks 0 days], transabdominal approach; single or first gestation) for the US -- depending on which trimester the mother-to-be is in.

" Modifier 26 (Professional component) appended to the US code to show that you are only coding for the physicians service, not the technical component of the code

" 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity) for the E/M

" Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and US were separate services

" 842.02 (Sprains and strains of wrist and hand; wrist; radiocarpal [joint] [ligament]) appended to 99283 and the US code to represent the patients wrist injury

" V71.3 (Observation following accident at work) and V22.2 (Pregnant state, incidental) appended to 99283 and the US code to provide further specifics on the patients condition

" E880.9 (Fall on or from stairs or steps; other stairs or steps) appended to 99283 and the US code to show the cause of the patients injury.