ED Coding and Reimbursement Alert

The rule of thumb for assigning E/M codes in the ED one service per physician, per patient per day has so many "buts" it could choke a pack-a-day smoker. ED coders must deal with patients who receive multiple services on the same day, or who remain in the ED for long periods of time, or whose patient status changes during their time in the ED. To apply E/M codes correctly for repeat visitors, you must thoroughly understand what a separate service entails, how to use modifier -25, and the definition of a day.

The three examples that follow will help you unravel the mysterious permutations of E/M for multiple visits to the ED. Mind Your Modifier First, let's look at two radically different services performed on the same day. A patient presents to the ED in the morning with lacerations in the right arm incurred after falling off a ladder while cutting down a tree, e.g., 880.0x, Open wound of shoulder and upper arm; without mention of complication. The ED physician should report the procedure code (e.g., 24341, Repair, tendon or muscle, upper arm or elbow) as well as the appropriate level of E/M visit (99281-99285, Emergency department visit). Later that day, the same person returns to the ED with a severe headache. The physician has already treated the lacerations, but now conducts a thorough E/M service to determine the headache's cause. Even if the headache is related to the first accident, the second evaluation is clearly distinct and significant, and should include a second E/M code with modifier -25 appended. Though guidance from CMS on modifier -25 has been out since 2001, confusion still abounds. The service "must meet the definition of 'significant, separately identifiable E/M service' as defined by CPT," emphasizes CMS Transmittal A-01-80 of June 29, 2001. In a nutshell, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when a separate and distinct history and physical were necessary.

In the above example, the services were rendered during two separate visits, but modifier -25 may also be appropriate in a case when the procedures happen at the same time. Because the headache could point to a head injury, says Alice Zentner, RHIA, director of education and outpatient coding at MedGrup, it is "going to require a completely different workup and is probably going to draw a higher level." Note: The facility side may append modifier -27 (Multiple outpatient hospital evaluation and management encounters on the same date) when reporting hospital resources related to separate and distinct E/M encounters performed on the same patient and provided by the same or different [...]