EM Coding Alert

Question: Our physician saw a one-year-old established patient that fell out of a shopping cart a few days earlier. The doctor decided that the patient needed to go to the operating room (OR) to be examined for a possible jaw fracture under anesthesia and at the same time have two teeth extracted. The doctor did a history and physical exam in the office before going to the OR. The doctor did end up extracting the two teeth but there was no evidence of a jaw fracture. How should I code the office part and the exam in the OR?

Colorado Subscriber

Answer: Your physician made the decision to go to the OR during the office service. Depending on the documentation, you would bill the appropriate office E/M service for established patient (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient, …) for the in-office E/M service. 

Attach 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) or 57 (Decision for surgery), depending on which your payer requires in this clinical situation. 

If the patient is going to be admitted to the hospital, combine the E/M service documentation in the office with the E/M service documentation in the hospital to determine the level of service. Where the issue presents is the place of service. Usually, payers will not pay for both an outpatient and an inpatient visit by the same provider on the same day.

Don’t miss: You should also report the appropriate tooth extraction code: 41899 (Unlisted procedure, dentoalveolar structures).