ED Coding and Reimbursement Alert

Question: A 35-year-old female presents to the ED with chest pain and a history of sickle cell disease. The ED physician ordered multiple labs including a CBC, CMP & PT/PTT/INR. The patient had a two-view chest x-ray that was read and interpreted by the ED physician. Narcotics and intravenous fluids were also administered to the patient during the course of care. A review of the medical record shows the following administration times:

After successful pain control is achieved, the patient is discharged with a diagnosis of sickle cell disease with vaso-occlusive crisis and chest pain without evidence of acute chest syndrome. The ED physician documents a detailed history and examination. What should we report for both the physician's work and for the facility services?

Answer: On the claim, you would report the following for the professional side:

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity...) for the E/M
• Modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99284 to show that the E/M and x-ray were separate services
• 71020 (Radiologic examination, chest, two views, frontal and lateral) for the chest x-ray
• Modifier 26 (Professional component) linked to 71020 to show you are only coding for the professional portion of the service

For the facility claim, you would report:

• Using a typical facility intervention based model to determine an E/M level, a 99284 is assigned (administration of infusions or parenteral meds & two types of diagnostic tests- labs & chest x-ray)
• Modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99284 to show that the E/M, therapeutic injections and hydration were separate services
• 96374 (Therapeutic, prophylactic, or diagnostic (specify substance or drug); intravenous push, single or initial substance/drug) to represent the IVP of Dilaudid @ 03:56
• 96375 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug [List separately in addition to code for primary procedure]) to represent the sequential IVP of Zofran @ 04:14
• 96376 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug [List separately in addition to code for primary procedure]) to represent the sequential IVP of Dilaudid @ 04:51
• 96361, 2 (Intravenous infusion, hydration; each additional hour [List separately in addition to code for primary procedure]) to capture the intravenous infusion of normal saline for one hour and thirty-two minutes.

Remember: When reporting hydrations, injections, and infusions we must observe the appropriate hierarchy; thus, only reporting one primary code. The hierarchy is as follows:

Infusion (96365) -- Injection (96374) -- Hydration (96360)

Don't forget to demonstrate medical necessity by appending these ICD-9 codes:

• 282.62 (Hb-SS disease with crisis) linked to E/M, hydration & injections
• 786.50 (Chest pain, unspecified) linked to x-ray

This is one circumstance when there is not much greater specificity available using ICD-10 coding. The equivalent ICD-10 code to 282.62 is:

• D57.00 (Hb-SS disease with crisis, unspecified)

The ICD-10 equivalent to 786.50 is:

• R07.9 (Chest pain, unspecified)

Editor's note: You Be the Coder coding scenario and advice provided by Eryn Lukic, Associate Director, Coding Operations at LogixHealth in Bedford, MA.