All Patients Are New to ED
Question: A patient presented to the ED with a 2-cm uncomplicated laceration to the hand. The physician repaired the laceration and sent the patient on his way. Is it appropriate to code just the procedure, or should I also report an E/M service? Answer: Usually, because the emergency department physician must assess the extent of the patient's injury before treating it, you will report both the procedure code and the appropriate evaluation and management code.
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Most of the time - especially in the ED, where every patient is new - the physician needs to obtain a history and understand the context of the injury or illness. This may involve ordering tests, such as x-rays, or prescribing medication.
While there are certainly cases in which the doctor has provided minimal documentation of the history and exam, which would preclude you from separately reporting an E/M service, most of the time that won't be the case. For the E/M service, you'll report one of the following codes:
