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ED Lac, 25 mod

Taylor Posted Fri 22nd of November, 2019 12:31:10 PM
We continue to get conflicting answers. Could you please clarify the usage of the 25 modifier for the ED MD only, not clinic? This lac was repaired, no tetanus or antibiotic given. Everything else needed for an E/M is present. I have read the “separately identifiable” paragraph, but would appreciate more direction when it comes to the ED. Thank you so very much! HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old male who presents to the emergency department with a laceration to the back of his right hand. He was working with sheet metal when the edge of his hand caught the edge of the sheet metal. It caused a small laceration at the base of his middle finger on the right hand. It bled profusely to begin with; in fact, he states it was spraying blood. The bleeding has since been controlled. His tetanus was boosted about 2 years ago. DENIES ANY ALLERGIES TO ANTIBIOTICS. Denies any numbness or tingling. He has good range of motion in all of his fingers. The sheet metal was otherwise clean. PHYSICAL EXAMINATION: GENERAL: The patient is a pleasant 53-year-old male. He appears in no acute distress. VITAL SIGNS: Reviewed and appropriate. NEUROLOGIC: Glasgow coma scale 15. Cranial nerves 2 through 12 grossly intact. He is moving all extremities equally. He has good sensation in the right hand distal to the laceration. SKIN: He has about a 1-cm laceration at the base of the right middle finger on the dorsum of the hand. It extends into the dermal layer, but does not extend deeper into the extensor tendons or other vasculature. It does not extend into the joint space. The wound is clean, free of debris or foreign body. Bleeding is scant.
SuperCoder Answered Mon 25th of November, 2019 08:36:47 AM

Hi Taylor,

 

Thanks for your question.

 

When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure.

 

The initial evaluation for minor surgical procedures is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery are included in the global package, unless a significant, separately identifiable service is also performed. So, E/M service cannot be reported separately in this scenario. You should report only repair of the wound of the finger.

 

Please refer the following link from CMS.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf

 

Please feel free to write if you have any question.

 

Thanks.

Taylor Posted Mon 25th of November, 2019 13:58:24 PM
Thank you! When I refer to https://www.supercoder.com/coding-newsletters/my-emergency-medicine-coding-alert/prove-separate-hem-for-proper-modifier-25-claims-article. titled Prove separate HEM for Proper Modifier 25 claims July 06,2006, we get confused. See Below portion below. -If a patient came in for a laceration repair, the physician is not going to just jump right in and start suturing. She is going to first talk about how the injury occurred, assess the wound and decide what suture material to use, etc.,- says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, coding analyst for CodeRyte Inc., national speaker, teacher of coding review courses, and former AAPC National Advisory Board member. Separate E/M almost a given: In the ED, physicians will almost universally provide a separate E/M, according to CPT rules. Based on federal mandate, all patients presenting to the ED need to have some type of evaluation to rule out an emergency medical condition under EMTALA. Just make sure the chart reflects these components and you will have likely satisfied the documentation requirements for a separate E/M service. Thank you again
SuperCoder Answered Tue 26th of November, 2019 02:47:21 AM

Thank you for more information.

This article says - Some ED patients, such as accident victims, will always require significantly separate E/M before the physician can decide how to proceed -- such as a car crash victim with multiple lacerations, possible broken bones, and a potential concussion.

 

When the physician's E/M service extends past the chief complaint for the injury, you may be able to report it separately with modifier 25 if you can prove the medical necessity and that the physician has provided a separate E/M.

 

As per CMS, (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO-19-15-EMTALA.pdf)

 

EMTALA only applies if the medical screening examination determines there is an emergency medical condition:

Emergency medical condition means—

1) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in—

i) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

ii) Serious impairment to bodily functions; or

iii) Serious dysfunction of any bodily organ or part; or

2) With respect to a pregnant woman who is having contractions—

i) That there is inadequate time to effect a safe transfer to another hospital before delivery; or

(ii) That transfer may pose a threat to the health or safety of the woman or the unborn child.

 

Not every patient that presents to a dedicated emergency department has an emergency medical condition.

 

Hope this helps.

 

Thanks.

Taylor Posted Tue 26th of November, 2019 10:15:54 AM
Thank you but would it be correct to say then that a scalp laceration would qualify for E/M-25 (significant identifiable E/M) in the ED? Example: The patient is a 3-year-old brought in by parents for evaluation of a laceration to the posterior scalp. He had stood up and hit the hitch on the truck, resulting in a laceration. There was no loss of consciousness. He has tolerated the injury fairly well. It did bleed quite extensively to begin with, but seems to be slowing down. PHYSICAL EXAMINATION: GENERAL: The patient is a cooperative 3-year-old, no acute distress. VITAL SIGNS: Pulse 104, respiratory rate 26, temperature 98.3, O2 saturation 100% on room air. NEUROPSYCH: Child is awake, alert, interactive, acting appropriately. HEENT: Patient is normocephalic. There is a 1.5 cm laceration to the occipital scalp on the right center posterior scalp. Wound extends into the dermal layer. Bleeding is scant. Wound appears to be clean and free of debris or foreign body. Intraocular and extraocular eye movements intact. TMs are clear bilaterally. PHYSICAL EXAMINATION: GENERAL: The patient is a cooperative 3-year-old, no acute distress. VITAL SIGNS: Pulse 104, respiratory rate 26, temperature 98.3, O2 saturation 100% on room air. NEUROPSYCH: Child is awake, alert, interactive, acting appropriately. HEENT: Patient is normocephalic. There is a 1.5 cm laceration to the occipital scalp on the right center posterior scalp. Repaired. Wound extends into the dermal layer. Bleeding is scant. Wound appears to be clean and free of debris or foreign body. Intraocular and extraocular eye movements intact. TMs are clear bilaterally. Child presents to the emergency department with a scalp laceration. He is not exhibiting any other worrisome symptoms to suggest a minor or major head injury.
SuperCoder Answered Wed 27th of November, 2019 02:59:36 AM

Hi,

 

When it is not clear whether the medical condition of the patient coming to ER, is an emergency medical condition or not, and whether evaluation and management can be performed or not, you may try billing E/M visit with modifier 25 along with the procedure performed in the ER. If your payer considers this eligible for payment, they will pay you. If they deny, they will tell you the reason of denial. You may proceed as per your payer's guidelines.

 
Hope this helps.
 
Thanks.

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