Question on emergency visit EM

[preema]

Hi, Patient presents to the emergency department after a fall and laceration to the hand. suture done for the laceration and Adacel IM (vaccination) given. Want to know about the emergency visit EM?

 

[TonyaMichelle]

In order to answer this we would have to look at the op report for sutures, the H&P and ROS to determine the E/M level. Please post it.

 

[preema]

EPF history and EPF exam. Also simple suture done.

 

[TonyaMichelle]

That would be E/M 99282 which will include, simple trauma not requiring X-ray ( simple suture), Tetanus booster (Adacel IM), and simple discharge information.

 

[preema]

Sorry, forgot to include that I am asking for professional EM. Just want to confirm whether can consider Adacel IM as prescription written and assign 99283.

 

[TonyaMichelle]

A RX med administration will boost the E/M code to 99283.

 

[mitchellde]

I am not seeing how the prescription gets this to a 99283. You still have 2 other MDM components that are on the straightforward side.

 

[TonyaMichelle]

This is one of the tools I go by for Emergency E/M:

Level I (99281)
1) Initial (triage) assessment
2)Wound Recheck
3) Suture removal
4) Note for work or school
5) Simple discharge information

Level 2 (99282)
Interventions from previous level plus any of the following:
1) OTC med administration
2) Tetanus booster
3) Bedside diagnostic tests (stool hemoccult, glucometer)
4) Visual Acuity
5) Orthostatic vital signs
6) Simple trauma not requiring x-ray
7) Simple discharge information

Level 3 (99283)
Interventions from previous level plus any of the following:
1)Heparin/saline lock
2) Crystalloid IV therapy
3) X-ray, one area
4) RX med administration
5) Flourescein stain
6) Quick Cath
7) Foley cath
8) Receipt of ambulance patient
9) Mental health emergencies (mild) not requiring parenteral medications or admission
10) Moderate complexity discharge instructions
11) Intermediate layered and complex laceration repair

And So Forth....

 

[mitchellde]

Oh I see for the facility level, but each facility has different criteria so it may be different for the poster. But for the physician you must follow either 95 or 97 guidelines and the ones you use would not work for the physician level every time. The provider level MD depends on 2 out of 3 criteria not just the risk which is the med management in this case but for the dx you still have minimal and for the complexity you still have minimal even though risk is moderate the MD is still straightforward. Give the information provided and not reading into it any more.