ED Coding and Reimbursement Alert

Question: An emergency physician is called to the inpatient setting by a floor nurse to care for an 84-year-old woman who was found on the floor near her bed. She suffered a 1.5 cm cut above her right eye. After a problem focused H&P, he determines the fall was simply caused by her getting tripped up by the sheets in the bed rail as she was going to the bathroom. The patient appears flustered and embarrassed but does not appear to have any confusion or focal neurological problems.

The physician examines her arm and wrist and determines it is not broken, but the cut requires a few sutures. He closes the wound with a simple repair and documents his services before returning to the ED. The entire encounter took about 20 minutes. How would you report this service?

Answer: On the claim, you would report:

99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination and medical decision making that is straightforward or of low complexity) for the E/M service

Append modifier 25 to 99231

12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) for the wound repair

Assign 873.42 (Other open wounds of the head; face, without mention of complication; forehead or eyebrow) to both 99231 and 12011

Also assign E884.4 (Accidental fall from bed) to describe the mechanism of injury to 99231 and 12011

Rationale: The documentation of the problem focused history and physical limits you to the lowest level subsequent hospital visit code. The E/M service that is separate from the laceration repair describes the cognitive work determining the cause of the fall and the absence of any other related injuries.