ED Coding and Reimbursement Alert

Patients with dental pain sometimes even arrive via ambulance.

The symptoms can range from migraine headaches to an inability to move the jaw — and sometimes even fevers that can cause patients to think they have the flu. Many emergency departments see patients present via ambulance with what turns out to be tooth pain, and even though ED physicians don’t perform standard dental work, they do treat these patients using a variety of methods.

If you see tooth pain diagnoses, consider these tips to ensure you’re coding properly.

Check out This Example

A 47-year-old female patient presents to the emergency department complaining of pain on the right side of her face, and a throbbing headache that’s affected her for the past four days. Her family is concerned that she might be having a mini stroke or a severe migraine. The patient is missing four teeth and reports she had them pulled due to abscesses and decay. On examination, it appears the patient has an abscess in one of her teeth in the upper-right side. The gum is swollen and tender, with a 2 mm lump under the gum which appears to be filled with pus. The ED physician gives the patient an antibiotic injection (Rocephin 250 mg) as well as a trigeminal nerve injection to control the pain. He also advises the patient to see a dentist within the next day, and prescribes a 10-day course of oral antibiotics to control the infection.

Do you know which codes are the most appropriate to report in this situation?

Start With the Procedure Codes

Your physician examined the patient and came to the diagnosis of an abscess, so you’ll select the appropriate ED E/M code (99281-99285, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components…) for the E/M portion of the visit. In addition, you’ll report 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) for the antibiotic injection and 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch) for the nerve block.

You’ll also submit the appropriate HCPCS codes for any drugs injected, such as J0696 (Injection, ceftriaxone sodium, per 250 mg) for the Rocephin.

Modifier alert: The National Correct Coding Initiative (NCCI) bundles 96372 into 64400, but you can separate the codes when warranted by appending a modifier such as 59 (Distinct procedural service) to 96372.

Because NCCI also bundles 96372 into the ED E/M codes, you’ll also want to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the ED E/M code that you select for the encounter.

Choose the Most Accurate Diagnosis Code

Although the patient presented with a headache and pain, you won’t need to report those symptom codes on your claim since the physician established a diagnosis of a tooth abscess. You’ll select the most appropriate dental abscess code based on whether the patient experienced a draining sinus:

• K04.6 (Periapical abscess with sinus)
• K04.7 (Periapical abscess without sinus)

It is not necessary to add any additional characters to these diagnosis codes.

Put It All Together

Assuming the physician performed a level-three E/M visit and the patient did not have sinus involvement in the abscess, your coding would look like this:

• 99283-25 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity…) for the E/M visit
• 64400 for the nerve block
• 96372-59 for the antibiotic injection
• J0696 for the Rocephin
• K04.7 as your diagnosis code, linked to the all above procedure codes.