ED Coding and Reimbursement Alert

The physician always performs some type of E/M preprocedure, and not all are separately reportable While it is important for coders in all specialties to know the rules for reporting separate evaluation and management services along with procedures on the same claim, knowing these rules may be even more important for ED coders.

When your ED physician performs an E/M service and then a procedure, and you can prove they are significant and separate, you can report the E/M using modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

If you have trouble deciding whether you have a modifier 25-eligible claim, follow this advice to see if you can report the E/M separately. Find Evidence of Separate E/M in Notes The most vital element on successful modifier 25 claims is concrete evidence that the procedure and E/M were truly separate, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J. All procedure codes have an inherent E/M component built into them, and the physician must go beyond that to justify a separate E/M.

For example, a Medicare patient presents with a simple finger laceration. The physician examines the finger and places two sutures. The physician's documentation is limited to an exam of the finger and scant history related to how the laceration occurred.

In Medicare's eyes, you have likely not met the requirements for a significant, separately identifiable E/M service; just report the procedure code on this claim.

Now check out this detailed scenario from Brink, in which the ED physician performs both procedures and a significant and separate E/M service:

A patient presents to ED via ambulance from a motorcycle accident. The bike hit a pothole, and the patient lost control, falling off the cycle and hitting his arms on the pavement. Both lacerations are contaminated with particulate matter, and the patient says his head and neck hurt.

The review of systems (ROS) reveals that the patient wears glasses and one hearing aid. He also has coronary artery disease (CAD) and takes 20 mg of Lipitor daily. All other systems were within normal limits (WNL). The patient has had no previous surgeries.

The exam reveals that the patient's head and face contain no contusions or lacerations. The patient has neck pain and restricted range of motion. Both of the forearm lacerations need extensive debridement to determine the extent of the injuries.

The physician conducts an 8-cm laceration single- layer repair on the right forearm with extensive debridement due to particulate matter and thus intermediate wound closure. He then performs a 6-cm laceration closure of the same complexity to the left forearm. After taking x-rays of the patient's [...]