ED Coding and Reimbursement Alert

Question: We saw a patient in the ED for a possible broken bone following a car accident. The ED physician diagnosed a fracture and a collapsed lung, and immediately arranged for the patient to be admitted to the hospital by a pulmonologist for treatment. Once the patient was admitted and in his inpatient bed, the ED physician examined an additional injury, which was a laceration sustained in the accident, and on the same day as the ED evaluation, repaired it. We reported an ED code and the claim was denied. I was always told to bill the E/M code based on where the patient is initially evaluated and that's why we submitted the ED code. Is this accurate, or should we have reported both codes?

Codify Subscriber

Answer: No, it isn't, you were correct to report the ED E/M service performed in the ED prior to the patient being moved up to the floor for inpatient treatment of the collapsed lung. Make sure your claim reflected place of service code 23 (Emergency department) for the ED E/M service. Since the physician performed the laceration evaluation while the patient was in an inpatient bed/status, you should report the appropriate code for the laceration repair based on location, length, and whether it was simple, intermediate, or complex.

Keep in mind that this is a rare situation, since typically the physician would evaluate the laceration in the ED. Based on your question, however, the physician wanted the patient evaluated for the collapsed lung as an inpatient sooner rather than later, and therefore repaired the laceration outside of the ED. But you should not report a second hospital care E/M service related to the laceration repair since you had already evaluated the patient in the ED setting and the place of service for the laceration repair would technically be POS 21 (Inpatient hospital)

Heed this: Payers are on the lookout for instances when two E/M codes are reported at the same time. Part B Recovery Audit Contractor Cotiviti announced on March 14 that it would be reviewing claims for when physicians report both observation care codes (initial, subsequent, and/or discharge management) for services that occur on the same day as an inpatient admission. Therefore, always be sure to just report one E/M code and not two.