ED Coding and Reimbursement Alert

Question: My group wants to report an E/M code along with this chart for a laceration repair, but I’m uncomfortable with the documentation as it appears justifying the addition service. Do you agree?

Physician Documentation:

HPI: The patient has a laceration related to: cooking, from a knife, occurred at home, and there are no complication factors. Cut with a knife.

ROS: no other complaints Exam: the wound is approximately 2 cm with a depth of 0.5 cm of the dorsal aspect of middle phalanx of left index finger. Procedure: Wound infiltrated with 1 mls of 1% lidocaine/buffered NaHCO3. Wound prep: Simple cleansing with Betadine by nurse. Skin closed with 3 4-0 Ethilon using simple interrupted. Dressed with per nursing. Patient tolerated well.

Impression: Finger Laceration

Kentucky Subscriber

Answer:  While most ED encounters require an EMTALA mandated screening exam for previously unknown patients the note above is very sparse and  close to the textbook example of when you should not report an E/M service with a procedure like a laceration repair, the uncomplicated cut at home with a clean kitchen knife with no other documentation.

Typically, you should look for some documentation not directly related to the procedure, perhaps dealing with the mechanism of injury or an associated sign or symptom. A fall with a head bump and possible loss of consciousness, or even some complications to the wound, heavy bleeding, numbness, or pain control would be reasonable arguments for the separate E/M.