tci ED Coding & Reimbursement Alert - 2019 Issue 2

Reader Question: Documentation Reigns With Burns

Question: A patient presented to the ED with a burn to his left eyelid after a spark from his fireplace burned him. Documentation only supports a level-two evaluation and management service, but I’ve never reported eye burn treatment before. Which E/M code should I report for this visit? Supercoder Subscriber Answer: Report 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem focused examination; and medical decision making of low complexity) for the eye burn treatment. Unfortunately, your doctor’s documentation may have...

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