ED Coding and Reimbursement Alert

Question: We had a patient present to the ED for a tetanus shot. Another physician had already examined her injury - a thorn puncture. Our physician looked at the wound, documented a problem-focused history and exam and ordered a tetanus shot. We generally code this evaluation and management service as "low," but could this be a moderate-risk service, due to the intramuscular injection and the potential for an adverse reaction?

Wisconsin Subscriber

Answer: You are correct to code this as a low-level service with 99281 (Emergency department visit for the evaluation and management of a patient, which requires these three components: a problem-focused history, a problem-focused examination, straightforward medical decision making). If you refer to the "clinical examples" section of the CPT manual under this code, one of the samples states the following: "Emergency department visit for a patient for tetanus toxoid immunization." So while your assessment of the moderate risk associated with this scenario may be on target, you should continue to report low-level E/M services for these situations - usually 99281.