tci ED Coding & Reimbursement Alert - 2016 Issue 3

Reader Question: It Might Sting A Bit If A Large Bill Is Received for "Just A Shot"

Question: If a patient presents to the ED for just a tetanus shot, can you also report an E/M service? The chart documentation shows a very brief exam of the wound and the physician ordered a tetanus shot. We generally code this evaluation and management (E/M) service as “low,” but could this be a moderate-risk service, due to the intramuscular injection and the potential for adverse reaction? Texas Subscriber Answer: If you refer to the “clinical examples” section of the CPT® manual under code 99281 (Emergency department visit for the evaluation and management of a patient...

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