EM Coding Alert

Question: One of my providers recently removed an ear piercing, and he documented that “the post was stuck, inflamed, and caused infection in the left ear helix.” They used two hemostats and unscrewed the post. No anesthesia and no incisions were necessary. Which procedure code would fit this best?

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Answer: Based on the information you provided, a standard ED evaluation and management (E/M) code is more appropriate for this encounter rather than a procedure code. The physician evaluated the patient’s condition, observed the inflammation and the infection, and was able to manage the problem without anesthesia or surgical intervention.

Typically, this work is included in an E/M service, which you would report with a code from the 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) set. Which E/M code you use will depend on the level of medical decision making (MDM) involved during the encounter.