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Documentation key for E/M plus procedure code

APCs Weekly Monitor, June 24, 2004

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QUESTION: We are billing for ED physicians and the hospital. If a patient presents to the ED and has a procedure performed (e.g., suture of laceration), is it appropriate to bill an E/M code and a procedure code on both the 1500 and the UB?

ANSWER: An ED encounter would usually include an E/M visit code and the procedure code. However, whether both can be billed depends on the services provided and the supporting documentation. The facility typically bills an ED E/M code on the UB for each ED encounter; but in order to support this charge, there must be adequate documentation. This documentation can include that of triaging of the patient, assessment by the ED nurse when the patient is taken to the ED bed, or services documented on the facilities acuity record. The triage, nurse assessment, or acuity record would qualify as being above and beyond the typical pre-procedure effort (if properly documented) and would typically qualify under most hospitals' E/M protocol for ED visits as a 99281-99285.

The facility should also report the laceration repair or other procedure documented by the physician and noted by the ED nurse. Therefore, both the procedure code and E/M with modifier -25 would be reported on the UB. Professional billing is beyond the scope of APCs Weekly Monitor, but again, it depends on how the physician documents the visit and procedure as to whether the E/M service meets the criteria for modifier -25.

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