Coding Emergency Department Procedures

The process of assigning an E&M code can be complicated, as coders responsible for doing so are aware. Although it is far beyond the intent of this article to explain all of the details of E&M coding, the example below should provide some insight into the steps involved.

Case Study

Chief Complaint: Burning in both of the patient’s eyes after some brake fluid splashed into them about 4 1/2 hours before presentation in the ED.

History of Present Illness: This 24-year-old male came in about 9:30 p.m. He states the amount of brake fluid splashed in his eyes was minimal, and he flushed his eyes with water afterwards and did not have any problems at that time. He states he went home and slept for a few hours and woke up with his eyes somewhat itching.

He states that he did not have any other problems, other than he might have noticed some blurriness at times.

Physical Examination: Vital signs are stable.

Eyes: Visual acuity at 20/20 OU with corrective lenses that he normally wears.

Findings: Instillation of proparacaine and fluorescein reveals two very small, very superficial corneal abrasions at the limbus of the cornea. The one on the right eye was at the 6 o’clock position, and the one on the left eye was at 3 o’clock.

Treatment Plan: Gentamicin ophthalmic two drops q2h OU wide awake for the next 3 days; Gentamicin ophthalmic ointment at night for the next 3 days OU. Follow-up with regular physician if condition worsens.

Impression: Chemical conjunctivitis, OU.

Hospital Code Assignments

This visit involves an E&M service. Although the CPT manual index lists codes 99281Ð99288 for Evaluation and Management, only codes 99281-99285 (ED services, new or established patients) would be considered for the hospital assignment. The reason is that 99288 relates to physician direction of emergency medical systems (EMS) emergency care.

One of these codes would be assigned, but which one depends upon the specific criteria that the hospital has established. There is little correlation between why a physician assigns an E&M code (costs for performing the service) and why the facility assigns an E&M code (overhead costs for providing the service). Until the Centers for Medicare and Medicaid Services (CMS) finalizes and implements an E&M code structure specifically for hospitals, they must use the same E&M codes as physicians.

However, now they must create their own definitions for codes 99281Ð99285. For this reason, a specific “correct” code for the E&M assignment is not given for the above example. The coder would make the assignment according to its facility-specific criteria.

The following ICD-9-CM codes would be assigned:

918.1 Superficial injury of cornea

Physician Code Assignments

The ED report supports assignment of an E&M code. After identifying the service provided in the documentation, and before choosing a code from the 99281-99288 range, a coder must determine the extent of the history, examination and medical decision-making—the key components of the service performed.

To do this, you must analyze the documentation according to the 1995 and 1997 E&M exam documentation guidelines issued by CMS. (Both sets of E&M documentation guidelines can be found at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp.) You may use either the 1995 or 1997 guidelines, whichever produces the best results for the provider.

Your analysis should lead you to the following, and from these elements, you would assign the appropriate CPT code:

History—expanded problem focused

Exam—expanded problem focused (1995 guidelines used)

Medical decision-making—moderate complexity

CPT Code Assignment

99283 Emergency department visit

ICD-9-CM Code Assignments

918.1 Superficial injury of cornea

Next month we’ll discuss more examples on hospital and physician coding of E&M services delivered in the ED.

Julianne Seaman is a senior health care consultant with Medical Learning Inc. (MedLearn^®), St. Paul, MN.