Medicare Compliance & Reimbursement

New CMS directive says claims with E codes as primary diagnoses unprocessable.

If you're submitting paper claims to Medicare with E codes in the primary diagnosis slot, don't expect a favorable response from the Centers for Medicare & Medicaid Services.

The agency has released a new directive that tells MACs to return as unprocessable claims submitted on the Form CMS-1500 where an ICD-9-CM 'E' code (external causes of injury and poisoning) is reported as the first/principal diagnosis on the claim.

Although this policy was already in place for electronic claims, the new announcement brings the policy for handling CMS-1500 claims into alignment with the policy for handling claims initially submitted in electronic format, according to MLN Matters article MM7700, released on Aug. 8.

If you could use a refresher on when E codes are appropriate, read on for some expert tips on how to use these diagnoses.

Put E Codes in Their Place

E codes represent external causes of injury and poisoning. According to the section introduction, E codes are provided to permit the classification of environmental events, circumstances, and conditions as the cause of injury, poisoning, and other adverse effects.

Important: The guidelines specify that you should report applicable E codes in addition to a code from one of the main chapters of ICD-9-CM, indicating the nature of the condition. You should never list them as the primary diagnosis, but instead you'll add them to offer a description of the event that caused the primary diagnosis.

Payers don't require E codes on claims. However, you can use an E code (and often more than one E code) to fully describe circumstances or establish medical necessity.

Example: A patient falls from a ladder while pruning shrubs during her volunteer shift at the community education center. She presents to the office complaining of pain in her lower left arm. You evaluate the patient and determine that her arm is bruised but not broken or sprained. You also evaluate her for other injuries and report a 99213 for the visit.

List a diagnosis code for a contusion of the forearm (923.10) as the primary diagnosis. But some payers might question the E/M level for the workup because the diagnosis is not specific. However, if you include E016.1 (Activities involving property and land maintenance, building and construction; gardening and landscaping), E849.6 (Place of occurrence; public building), and E881.0 (Fall on or from ladders or scaffolding; fall from ladder), the payer would have information justifying workup and, possibly, x-rays to check for a fracture or more severe injury.

Get to Know These Crucial E Code Basics

According to ICD-9, the main purpose of E codes is to statistically track the incidence of accidental injury. For example, the well known statistic that most accidents happen in the home was obtained through the use of E-code tracking.

E codes do not change your reimbursement amount because they are considered for informational purposes only codes. They can help speed up the reimbursement you're due, however, because insurers may have fewer follow-up questions about your claims if E codes give them a fuller picture of a patient's diagnosis. Plus, in cases where your patient is injured by a moving car, either as a pedestrian, bike rider, or passenger, you'll often have to deal with auto insurers, which may require E codes.

Check for Common 'E' Codes in Your Practice

If you think E codes don't apply to you, consider these possibilities: Have you ever treated a patient for a dog bite? How about a bee sting? Or an allergic reaction to antibiotics? These are all covered in ICD-9's E code section. Keep the following common family medicine E codes in mind when you're selecting your diagnoses going forward:

• E001.x -- Activities involving walking and running
• E006.x -- Activities involving other sports and athletics played individually
• E007.x -- Activities involving other sports and athletics played as a team or group
• E010.9 -- Other activity involving other muscle strengthening exercises
• E812.x -- Other motor vehicle traffic accident involving collision with motor vehicle
• E813.x -- Motor vehicle traffic accident involving collision with other vehicle
• E849.0 -- Place of occurrence; home
• E849.6 -- Accidents occurring in public building
• E888.9 -- Unspecified fall