Primary Care Coding Alert

Question: An established patient presents to the FP after an accident; he crushed the tip of his right thumb while putting up folding chairs after a party. After a level-two E/M, the FP used trephination to evacuate a subungual hematoma, according to the notes. How should I code this procedure? Michigan Subscriber Answer: On your claim, report the following: • 11740 (Evacuation of subungual hematoma) for the evacuation (i.e., trephination); • 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) for the E/M; • modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99212 to show that the E/M and evacuation were separate services; • [...]