ED Coding and Reimbursement Alert

This expert coder breaks down the answers to your most pressing ED questions.

Coding for an emergency department often has its own set of challenges. While most codes are filed in the same style as outpatient claims, other rules such as incident-to are completely different. And although the services take place in a hospital, the inpatient rules don't quite apply either.

That's why ED Coding Alert brought in expert coder Sharon Nicka, RN, CPC, of Nicka & Associates in McKinney, Texas, to answer three of the most common questions that have been submitted to our editors this year. Read on for Nicka's sage advice.

1. Two Visits, Same Day Might Lead to Two Codes - But Not Usually

It happens every now and then - a patient presents to the ED twice (or more) in the same day. For instance, the patient has an uncontrollable bloody nose in the morning and returns in the afternoon because the nose began bleeding again.

Although it's tempting to report two different codes for the separate services, that's the wrong way to code, Nicka says. "A frequent approach is to roll both visits into one code, adding together the notes from both to establish the level of service to report."

The reason, she says, is that payers will not reimburse you for two separate E/M visits on the same date of service. "It doesn't matter what modifier you use, unless there's a different diagnosis, you frequently won't be successful in billing both visits separately."

As Nicka mentioned, however, many payers will reimburse you separately for both visits if they are for two different problems. For instance, if a patient presents in the morning after falling out of a tree and breaking her arm and then comes back again in the afternoon with an asthma attack, you may be able to collect for both.

The Medicare Claims Processing Manual states in chapter 12, "The Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter."

Do this for unrelated visits: Part B MAC Palmetto GBA offers the following recommendation for those that do report two E/Ms on the same date to describe separate diagnoses: "If the reason for the second visit is an unrelated problem that could not have been addressed in the first encounter, the reason for the second visit must be clearly documented in the documentation field of the electronic claim or as an attachment to the CMS-1500 Claim Form."

2. Modifiers Are Essential in the ED

Nearly every ED visit requires an E/M encounter, and many visits also require a procedure or diagnostic test as well. This means that you'll often have a need to use modifiers in the ED setting, Nicka said.

"When the encounter is for an E/M visit and then a procedure is provided during that encounter, a modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) is required," Nicka said. "Without the 25, it will not be paid."

For instance: A patient reports to the ED after stepping on a piece of glass at a picnic. After examining the patient and making sure the wound is free of debris, the ED physician repairs the 0.8 cm right foot defect with sutures. Notes indicate a level-three E/M service. On the claim, report the following:

• 99283-25 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of moderate complexity...) for the E/M
• 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) for the repair

Likewise, modifier 59 (Distinct Procedural Service) is essential when you perform more than one procedure.

Example: A patient presents with a finger laceration and a noncontiguous nail bed injury on the same finger. As these are two distinct injuries and not connected, then the 59 modifier would be appropriate to indicate separate noncontiguous procedures. Your coding would appear as follows:

• 11760 (Repair of nail bed)
• 12001-59 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less, Distinct Procedural Service)

3. Code Those Comorbid Conditions

It can be confusing to see scores of diagnosis codes in a patient's chart, but knowing the order in which you should report them is essential to accurate coding, Nicka says. For instance, suppose a patient with a history of breast cancer and existing glaucoma comes with fractured leg.

"Sequencing is so important, and you have to ask yourself why the patient came to the ED," Nicka says. "In this case, it was a fractured leg. The comorbidities will make a difference on how that patient is treated and managed, and with ICD-10, you need great detail, so code those comorbidities after the current diagnosis if they are documented as relevant to the ED encounter."

In black and white: "For outpatient claims, providers report the full diagnosis code for the diagnosis shown to be chiefly responsible for the outpatient services," CMS says in Section 10.3 of Chapter 23 of the Medicare Claims Processing Manual.

"For instance," the Manual says, "if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported. If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported."