ED Coding and Reimbursement Alert

Question: I have a question regarding whether to apply both the E/M code and the procedure code for a service performed by the ED physician. 

The documentation records that a father brought his son in for a swollen finger with pus draining from where it had been punctured. The physician performed an examination which revealed swelling along the radial aspect of the right index fingernail fold into the base of the nail. The volar pad was soft, with no swelling or inflammation proximal to the DIP joint. The rest of the right hand and arm were also examined for signs of spreading infection.

The ED physician prepped the finger and made a 7mm incision to drain the pus. The wound was then irrigated and a small amount of pus was drained from the wound with a 5 mm tab of iodoform placed.. The nail was not removed. The patient was started on antibiotics.

Should I apply both 99282-25 and 10060-54 to this event, or should I only report the 10060-54 since the exam pertained only to the finger?

Florida Subscriber

Answer: You should code the straightforward drainage of a paronychia with 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single).

 If a 10060 procedure was performed and no prescription was given, then 99282-25 could be appropriate assuming the documentation requirements were met. In this case, the doctor also treated a large collection of pus located at the nail fold that required a 7mm incision and some packing; usually a paronychia would require no more than a few millimeters of incision and no packing. Therefore, one could also make the argument that this was not “simple” and that 10061 (… complicated or multiple) would apply.

With regard to the addition of an E/M code, most coders would feel comfortable submitting an E/M code if the documentation mentioned additional exam components, or screening for advancing or systemic infection.

In this particular case, the emergency physician separately examined the finger and arm for signs of lymphangitis, cellulitis or a tenosynovitis with perhaps even a consideration of an osteomyelitis above and beyond the drainage of the paronychia.  A prescription for antibiotics was also written.

As long as the physician documented all these findings, you could consider an E/M service with a 25 modifier in addition to the procedure.

In addition, do not apply the 54 modifier to either 10060 or 10061 since there is usually minimal follow up required. If the patient does return within 10 days for a related complaint or minor complication and he is a Medicare patient (obviously not the case for this little boy), a second E/M would not be appropriate as it would fall within the 10 day global fee period.