Wiki E/M & Laceration clarification

[ivonneatanacio]

I have a provider who asked the following:

I have one specific coding question for you that could affect a fairly large number of patients.We had been advised in the past to code ALL lacerations as a level 3 (new or established patient) because the repair procedure (sutures, skin staples, or skin adhesive) will be billed in addition to the E&M code.

I just spoke with the COO of a pediatric urgent care practice in Texas and we discussed this. She told me that their providers code ALL lacerations requiring repair as a level 4 because of the medical decision making involved. I have always thought that lacerations requiring repair should be level 4, but we never pursued this. I believe that superficial lacerations that do not require repair should always be coded as level 3.



Thoughts?

 

[thomas7331]

Are you speaking of the professional or facility claim?

For professional services, you cannot generalize a code level based on this limited amount of information - code levels have to be chosen based on individual documentation of the specific patient's condition and the provider work that was done. There are many factors that could influence the level of the E&M service beyond whether or not the laceration required repair. While I would agree a superficial laceration in an otherwise healthy patient is unlikely to warrant moderate MDM or a level 4, it is really imperative to evaluate the documented details of each individual case to determine the appropriate level of service to bill.

 

[moeslilmom]

Yes! I agree Thomas! Medical Decision Making alone NEVER should be used when determining a visit level! You MUST educate your practice on this! The appropriate history and/or exam must also be documented depending on whether it is a new patient or established patient. I would gather documentation explaining the abuse/fraud definitions and how an E/M level is determined to back you up. I have found that even though I know my providers trust my knowledge, it just reassures them by seeing it for themselves that I am not misinterpreting the rules/guidelines or something else. If they really feel that they perform at these levels at each visit, you have to teach them the importance of proper documentation!! Once an audit is performed and the records are reviewed, they can't go back and say "well I did this, but didn't put it in the note" or use other excuses. Unfortunately, ignorance to these guidelines cannot be used to overturn an overpayment request and/or lawsuit/penalty/fine for these oversights!

Following these guidelines is going to be so important in the age of EMR/EHR. It is so easy now for insurances (commercial and government) to gather data, create queries/logarithms, etc. to establish patterns in over-coding and other forms of abuse/fraud by tying diagnosis codes and E/M levels together!