Neurology & Pain Management Coding Alert

Question: The PM physician treated a patient with shoulder pain in the emergency department (ED). After an evaluation and management (E/M) that included low-level medical decision making (MDM), the physician orders and interprets a two-view shoulder X-ray. Final diagnosis was right shoulder pain. How should I report this encounter? Can I use ED E/M codes for this patient?

Illinois Subscriber

Answer: As long as the physician treated the patient in an ED setting, then you can use the ED E/M codes 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).

The National Hospital Ambulatory Medical Care Survey (NHAMCS) defines an ED setting as a hospital facility that is staffed 24 hours a day, seven days a week, and provides unscheduled outpatient services to patients whose condition requires immediate care.

So, assuming your physician was working in an ED setting, you’d report:

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making) for the E/M
• 73030 (Radiologic examination, shoulder; complete, minimum of 2 views) for the X-ray
• Modifier RT (Right side) appended to 73030 to indicate laterality
• Modifier 26 (Professional component) appended to 73030 to show that you are only coding for the professional portion of 73030, not the technical portion
• M25.511 (Pain in right shoulder) appended to 99283 and 73030 to represent the patient’s shoulder pain

Otherwise: If the physician is not working in an ED setting, you’ll have to choose from the other hospital/inpatient E/M codes for the service.

Never do this: No matter what you do, do not report E/M codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.). These are for office/ outpatient encounters only, and you’d never use them for a facility E/M.