General Surgery Coding Alert
What's the Dx for Asymptomatic Patient?
Question: Our surgeon recently treated two patients in the emergency department (ED) who were injured when their car veered off the highway. There was also a third passenger in the vehicle who was not hurt, but she was exposed to blood during the accident. The physician performed a level-two E/M service before releasing the non-injured patient. How can we prove medical necessity for the E/M service?
North Carolina Subscriber
Answer: You may use a V code as a primary diagnosis because the patient is asymptomatic.
On your claim:
- report 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem- focused history; an expanded problem-focused examination; and medical decision-making of low complexity) for the E/M.
- attach V15.85 (Other specified personal history presenting hazards to health; exposure to potentially hazardous body fluids) to 99282 to represent the reasons for the patient's visit.
- attach E816.1 (Motor vehicle traffic accident due to loss of control, without collision on the highway; passenger in motor vehicle other than motorcycle) to 99282 to show that the patient was in an accident.
- attach V71.4 (Observation following other accident) to 99282 to show that the physician observed the patient after an accident.
If the patient has any symptoms at all, however, you would slide V15.85 into the secondary position.
For instance, the patient who was exposed to the blood also complains of pain near her ribs during the encounter. The physician performs a level-two E/M, checking the patient's shoulder in addition to examining her exposure to blood.
On the claim, you would:
- report 99282 for the E/M.
- attach 786.50 (Chest pain, unspecified) to 99282 to represent the patient's rib pain.
- attach V15.85 to show that the patient was also exposed to blood.
- attach E816.1 to 99282 to show that the patient was in an accident.
- attach V71.4 to 99282 to show that the physician observed the patient after an accident.
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