General Surgery Coding Alert

Without a separate dx, you won't report ED and other E/M service together You already know that your surgeon can report 99281-99285 if she attends to a patient in the emergency department (ED) -- although you may be better off choosing a consultation or inpatient admission code, depending on the circumstances. What you may not know is how to report ED E/M services when combined with a same-day procedure or another, same-day E/M service. Read on for four more tips -- in addition to those you learned in Part 1 of this series, "Revive Your ED E/M Coding, STAT," in General Surgery Coding Alert, Vol. 10, No. 2 -- to complete your knowledge of how to handle your ED coding claims. Tip 1: Same-Day Procedure, E/M Requires Modifier If your physician provides an ED service and, based on that service, then performs a minor procedure (a procedure with a zero- or 10-day global period) on the same date of service, you-ll want to append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the ED code. This tells the payer that the ED service was separate and significantly above the procedure's "inherent" E/M component, says Kate Kibat, CPC, compliance educator at the University of Washington Physicians in Seattle. The documentation should reflect that the physician workup includes more than just the problem-focused service that is typically part of a procedure, and that as a result of the E/M, the physician determined to perform the procedure. The payer has to be able to see from the chart that the E/M is not the minor E/M (history, exam and medical decision-making) built into all medical procedures. Example: A patient with a long laceration on the left forearm presents to the ED. The physician performs an E/M service and documents a history, exam and MDM to evaluate the patient, determine if there are other injuries and decide on the best course of treatment. He then performs a simple repair of the wound (for example, 12006, Simple repair of superficial wounds of scalp, neck axillae, external genitalia, trunk and/or extremities [including hands and feet]; 20.1 to 30.0 cm). In this case, you would report 12006 for the wound repair, plus the appropriate-level E/M service (such as 99282). You should append modifier 25 to the E/M service to differentiate the service as significant and separately identifiable, Kibat says. Reserve 57 for Major Procedures When the physician provides an ED service and, based on that service, performs a major surgical procedure (any procedure with a 90-day global period) on the same or the next date of service, you should append modifier 57 (Decision [...]