E/M Coding Essentials: Understanding the Coding for Both Hospital’s and Physician’s Side

Let's take a little warm-up exercise. This is an ED encounter. We're out at the fictitious Apex Medical Center ED and we have an individual that's presenting with a laceration on the arm. The individual accidentally sustained a laceration while washing his car, specifically the windshield wiper blades. And for those of you that wash cars, you have to be a little bit careful about those windshield wiper blades. The ER nurse performs an assessment and determines that there are no other presenting symptoms other than the laceration on the arm.

The hospital is required to do a medical screening examination by qualified medical person. And in some cases, this can include nurses.

The individual's tetanus booster is current. The nurse takes the patient to an ER bay, thoroughly cleanses the wound and obtains a suture repair kit for the ER physician. The ER physician repairs the laceration with two sutures and wound adhesives.

We want to code this on both the physician side and the hospital side. Now, I don't know what kind of an evaluation the physician did. In actuality, we don’t think the physician did much of an evaluation at all. The only thing the physician did was to suture the wound. And in that case, the physician will only code suturing of the code. Maybe it's a 12002 for CPT code.

But on the hospital side, we have consumed resources for the evaluation of the patient and then the repair of the laceration. So on the hospital side; we're going to code, for instance, the 12002 laceration repair code along with an evaluation management code.

Some of us make it a 99282 – make it a 99282. Now, since we've used an E/M level 99282 and a surgical procedure 12002, we will have to use the -25 modifier on the 99282. This seems pretty straightforward. The only thing unusual in this exercise is that the physician may not code an E/M level because the physician may not have done a
general examination.

Now, if the physician did do a general examination, then the physician would also code, say, a 99282, whatever is appropriate, based upon the history, the exam, the medical decision making. And the physician would also have to use a -25 modifier. Now, this is part of the reason why these things become just a little bit tricky all the way around.