ED Coding and Reimbursement Alert

Question: A patient reports to the ED with an ingrown toenail. During the exam, the physician notices that the patient also has an infected foot wound and administers an intravenous antibiotic. In this scenario, in addition to the appropriate code for the toenail excision, can you report a separate and significant evaluation and management (E/M) service for the unrelated infected foot wound using modifier 25 along with the appropriate E/M code?

West Virginia Subscriber

Answer: Yes, you can use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) in this scenario. This modifier applies when a provider or other qualified healthcare professional performs an E/M service on the same day as another service to the same patient by the same physician, regardless of whether a patient is new or established.

In this situation, the provider treats a problem (the foot infection) that is separate from the other problem that originally caused the patient to present for the encounter (the ingrown toenail excision). As the problem is separate and significant, you can bill for both the procedure and the appropriate E/M code from 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making), appending modifier 25 to the E/M code.

In this scenario, you would not also bill for 96379 (Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion) because CPT® explicitly states hydration, injection and infusions codes are not paid separately in the facility including the ED setting.

Pro coding tip: There are a few basic same-day situations to look for that may justify the use of modifier 25. In The ED, based on the broad evaluation that is federally mandated by the Emergency Medical Treatment & Labor Act (EMTALA), the lack of established patient relationships and the nature of acute episodic unscheduled care, an E/M service will almost always be appropriate.

There are multiple examples in CPT^®, such as patients presenting for elbow pain but then upon evaluation requiring an arthrocentesis, which support the use of the 25 modifier, particularly in the ED setting.

Keep in mind that per 2024 CPT^®:

“The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.”