ED Coding and Reimbursement Alert

These 3 scenarios all look like procedures, but 2 are actually E/Ms.

Sometimes, encounter notes will play tricks on you in the ED: patients reporting with certain injuries might require services equaling a procedure code ... though some only require an E/M service.

Sidestep coding quicksand and deliver the right claim on time, every time, with this expert input on walking the E/Mprocedure line in the following three scenarios.

Myth 1: Wound Repair Wraps Up Laceration

Fix Code Patients reporting to the ED with lacerations will typically require laceration repair -- though the service might not reach the procedure level, confirms Kenny Engel, CPC, CHC, ACS-EM, CCP, chief compliance officer with Martin Gottlieb Associates in Jacksonville, Fla.

You might be able to report a simple repair according to the length and body area using 12001-12018 (Simple repair of superficial wounds of ...), says Engel. However, "the scenario where you would not code a simple closure, but rather an E/M code, would be the minor wound that is closed with simple adhesive strips," he explains.

Your provider might refer to these adhesive materials as streristrips, Band Aids, or "butterflies." When the physician only uses these materials to close a wound, opt for a 99281-99285 code based on encounter notes.

For Elderly Patients, Double-Check Wound Repair Claims

In the ED, you might see the provider using only adhesive strips to close wounds on patients with weakened skin. "We often see this scenario played out with elderly patients that present with minor lacerations. It is common for older patients to have very fragile skin, which may not support sutures," says Engel.

With these types of patients, the physician might "just use steristrips to close the wound. When only steri-strips are used, the coder may only bill an E/M code and not a repair," he explains.

Myth 2: Instrumentation Matters on Conjunctival FBRs

Actually, the conjunctival foreign body removal (FBR) codes do not call for specific instrumentation. "Anything from a Qtip to a diamond-tipped bur, needle, tweezers, golf spud, or an algerbrush" might be used for this eye FBR, says David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas.

Translation: If the physician removes an FB from a patient's conjunctiva, odds are that an FBR procedure took place (65205-65210). Code according to the notes, but be on the lookout for an eye FBR coding opportunity each time the provider removes something from a patient's conjunctiva ��" even if the removal method is something as simple as saline irrigation or a swab.

Example: A patient reports to the ED complaining of eye pain. After a level-three E/M service, a qualified nonphysician practitioner (NPP) diagnoses "FB, conjunctival sac, superficial." Using saline irrigation and the tip of a cotton swab, the NPP removes the FB and sends the patient home.

Despite the simple removal methods, this qualifies as an eye FBR. On the claim, report the following: 65205 (Removal of foreign body, external eye; conjunctival superficial) for the FBR 99283 (... an expanded problem focused history; an expanded problem focused examination; and moderate medical decision making ... ) for the E/M service 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 99283 to show that the E/M and FBR were separate services

930.1 (Foreign body on external eye; foreign body in conjunctival sac) appended to 65205 and 99283 to represent the patient's FB.

Myth 3: Earwax Removal Means 69210

Not necessarily, says Sandra Pinckney, CPC, PCS, office manager at Certified Emergency Medicine Specialists in Grand Rapids, Mich. When considering 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) "there are a couple of things that must be taken into consideration," she says.

First: You must confirm that the cerumen clinically impacted.

Pinckney cites the July 2005 CPT Assistant, which states that cerumen is "impacted" clinically if it: impairs the exam of the external auditory canal, tympanic membrane, or middle ear condition; or is extremely hard and dry, and causes the patient pain, itching, hearing loss, etc.; or cerumen has caused inflammatory response associated with foul odor, infection or dermatitis; or is obstructive, in copious amounts that cannot be removed without magnification and multiple instrumentations requiring physician skills.

Second: In order to report 69210, the physician must remove clinically impacted cerumen using, at minimum, "an otoscope along with wax currettes, forceps, or suction," relays Pinckney. Even 'Impacted' Dx Does not Guarantee Procedure Simply irrigating soft cerumen would not be separately billable from your E/M, Pinckney continues, and offers this example.

Example: A patient presents to the ED with discomfort in one ear. The nurse practitioner (NP) lavages some of the soft cerumen out. The physician then instructs the patient on using ear drops in order to break up the remaining wax.

In this scenario, you'd code an E/M for the entire service, such as 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision making of low complexity ...).