Inpatient Facility Coding & Compliance Alert

Question: A patient presented to the ED with an uncomplicated laceration to the hand. The physician repaired the laceration and discharged the patient. Typically, we code this evaluation and management (E/M) service as “low,” but could this be a moderate-risk service, depending on the extent of the severity of the laceration? Is it appropriate to code just the procedure, or should I also report an E/M service?

Michigan Subscriber

Answer: Usually, the ED physician assesses the extent of the patient’s injury before treating it, and you will report both the procedure code and the appropriate E/M code.

Most of the time, especially in the ED, where every patient is considered new, the physician needs to obtain a history and understand the context of the injury or illness. This may involve ordering tests, such as x-rays, or prescribing medication.

In the case of patients with whom the doctor has provided minimum documentation of the history and exam, you will not be able to separately report an E/M service. For the E/M service, you’ll report one of the following codes:

• 99281 — Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor.
• 99282 — …An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity…Usually, the presenting problem(s) are of low to moderate severity
• 99283 — …An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity…Usually, the presenting problem(s) are of moderate severity.
• 99284 — …A detailed history; A detailed examination; and Medical decision making of moderate complexity… Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.
• 99825 — Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

To code the ER E/M level along with the laceration repair, the 25 modifier must be used on the E/M level.  Determining when the E/M level can be coded and billed is also complicated by EMTALA (Emergency Medical Treatment and Labor Act).  EMTALA requires that the hospital have a Medical Screening Examination (MSE) performed by a qualified medical person. Generally, the ER physician will perform this more general assessment although nursing staff can, in certain instances, be qualified to meet this requirement.  If the physician does perform the MSE, then there will certainly be an E/M level.  However, if a nurse performs the MSE and the physician only repairs the laceration, then the ER physician will probably not code and E/M level.

To add to an already complex situation, the Medicare NCCI (National Correct Coding Initiative) has a policy statement that when a minor surgery (10-day postoperative period) is performed, it is assumed that the E/M services are bundled into the minor surgery.  While this is quite reasonable for physician clinics, it is questionable for ER services.  (See General Correct Coding Policies For National Correct Coding Initiative Policy Manual For Medicare Services, Chapter 1, Pages 17 and 18).