Emergency Department Coding Rules (CPT 99281-99285)

Emergency Department (ED) Coding basic information

Their has been lot of updates in Emergency department coding this year and it has really made easy to choose levels in ED coding. Now, Medical Decision Making is the main factor to choose the level of ED CPT codes 99281-99285.

Emergency department is basically for patients requiring immediate medical attention. Since the codes now based only on level of medical decision-making. Their are elements that will help determine the correct MDM level for ED services. Below are few of them

• Possible number of diagnoses to which the signs and symptoms indicate
• The patient’s current co-morbidities that may relate to or affect this current condition or
  treatment
• Current additional evidence-based research that may reveal new treatments available, such
  as new FDA-approved medications, FDA-approved devices, and other literature

If their are some consultation in ED those will reported with Office or Outpatient Consultations CPT codes 99241 – 99245.

Different Modifiers used with ED CPT codes (99281-99285)

• Modifier 25 Significant Separately Identifiable E/M
• -52 (reduced services)
• -53 (discontinued procedure)
• -54 (surgical care only)
• -55 (post-operative management only)
• -56 (pre-operative management only)
• –59 (distinct procedural service)

Procedure or CPT codes, Services, Treatments in ED Facility

Below are some of the services or procedure done in ED facility for immediate action.

• Imaging and lab work
• Cast application -cast is required after a surgical manipulation of a fracture, it is already included in the surgical code. Cast application is only reported from 29000 – 29585 when an existing cast must be replaced
• Wound repair
• Debridement
• Penetrating trauma wounds

Outpatient or Ancillary service done in ED facility 

• Imaging or X-ray
•  CT scan
• MRI 

All these exams are used to determine type of fracture , severity of fracture or dislocation,  location of foreign object etc.

Ancillary Services: Lab work

As per the patient status, lab procedures are ordered. For example,
• General health panel (80050) = looking for inflammation, other appropriate issues
• Per situation:
– Drug assay (80305 – 80377)
– Therapeutic drug assay (80143 – 80299)

Coding for Wound Repair (closure)

Their are different CPT code for Simple , intermediate and Complex repair

Simple repair: CPT code 12001-12021
Intermediate repair: CPT code 12031-12057
Complex repair: CPT code 13100-13160

To code wound repair codes, the coders should first determine level of repair required, determine specific anatomical site, group same level of repair + anatomical site together into one code

But wound debridement has different level  codes (CPT code 11000-11047)

The debridement codes depends on the depth of tissue being removed (deepest level is reported) and surface area of wound. For multiple wounds, add the surface areas that are the same depth.

For Penetrating Wounds we have separate level of codes (CPT code 20100 – 20103)

The coding for these codes depends on –
• Surgical exploration of wound
• Extension of dissection to determine penetration
• Debridement
• Removal of foreign body
• Ligation or coagulation of blood vessels