tci ED Coding & Reimbursement Alert - 2014 Issue 5

Reader Question: Make a Careful ID of What Service Was Provided for Incision, Drainage Procedures

Question: The ED physician performs a level-four E/M service for a patient and diagnoses a peritonsillar abscess. Notes indicate that the physician aspirates the abscess to confirm the presence of pus and then incised and drained. How should I code this encounter? Minnesota Subscriber Answer: For this encounter you would report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: detailed history; a detailed examination; and medical decision making of moderate complexity ...) for the E/M Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on...

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