EM Coding Alert

Question: A new patient presents to the ED after falling from a balcony. The patient complains of pain in their right pectoral and rib area. During the examination, the ED physician notes that the area is tender to the touch and slightly swollen. The patient rates the pain as 6 on a scale of 10. The emergency physician orders a four-view X-ray including posteroanterior chest, which they interpret and confirm a right chest contusion and bruised ribs. The physician prescribes rest and nonsteroidal anti-inflam­matory drugs (NSAIDs) and sends the patient home. How should I report this encounter? Can I code separately for the ED physician’s treatment of the chest/ribs?

AAPC Forum Subscriber

Answer: Your physician’s treatment of the patient’s ribs isn’t separately reportable You can, however, consider the treatment when deciding on the overall level of the evaluation and management (E/M) service. In addition to the physical and exam, you should factor the X-ray order/ interpretation and the physician’s advice to the patient when deciding on an E/M code.

E/M level: The type and severity of the injury are indicative of an acute complicated injury indicating a moderate complexity of problems addressed (COPA). The order for the X-ray is one Category 1 point for ordering of each unique test; if documented, the ED physician’s independent interpretation of the X-ray would count in Category 2 for independent interpretation of a test. These elements would support moderate data. The prescription for NSAIDs would support moderate risk for prescription drug management.

Moderate COPA, moderate data, and moderate risk combine to support a level-four ED E/M service.

On the claim, you should report:

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level medical decision making) for the E/M
• S20.219A (Contusion of unspecified front wall of thorax, initial encounter) appended to 99284 to represent the patient’s rib bruises
• S20.01XA (Contusion of right breast, initial encounter) appended to 99284 to represent the patient’s chest bruise
• W13.0XXA (Fall from, out of or through balcony, initial encounter) appended to 99284 to represent the cause of the patient’s injuries.