ED Coding and Reimbursement Alert

Certain E/M services are built in to procedure codes When a patient reports to the ED for treatment of a specific injury or illness, the physician usually performs some evaluation and management service along with the procedure.
 
Issues: What E/M services are bundled into the procedure code, and how can you tell whether an encounter involved enough service to report a separate E/M?
 
If you can't answer these questions, you won't know whether it is possible to report a separate E/M with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in addition to the procedure code. Identify Procedures With Inherent E/Ms According to experts, your physician will provide certain services that are components of the procedure code and cannot be reported as separate E/Ms.
 
-If a patient came in for a laceration repair, the physician is not going to just jump right in and start suturing. She is going to first talk about how the injury occurred, assess the wound and decide what suture material to use, etc.,- says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, coding analyst for CodeRyte Inc., national speaker, teacher of coding review courses, and former AAPC National Advisory Board member.
 
Some ED patients, such as accident victims, will always require significantly separate E/M before the physician can decide how to proceed -- such as a car crash victim with multiple lacerations, possible broken bones, and a potential concussion.
 
When the physician's E/M service extends past the chief complaint for the injury, you may be able to report it separately -- if you can prove the physician provided a separate E/M, -something more than the minor E/M that is included with the procedure,- says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, of CRN Healthcare Solutions in Tinton Falls, N.J. The physician might also provide a separate E/M when a patient reports for a procedure or service, then reports a totally separate complaint during the encounter.
 
Separate E/M almost a given: In the ED, physicians will almost universally provide a separate E/M, according to CPT rules. Based on federal mandate, all patients presenting to the ED need to have some type of evaluation to rule out an emergency medical condition under EMTALA. Just make sure the chart reflects these components and you will have likely satisfied the documentation requirements for a separate E/M service.
 
Both CPT and CMS agree that a separate diagnosis is not required to justify a separate E/M service. However, commonly used payer edits will make your claims processing a bit easier if each reported CPT code has a corresponding unique ICD-9 code. Try Singing the -HEM Song- Deciding whether your [...]