The article “You Code It! Integumentary Repair” earlier in this newsletter asked which codes would be assigned for an emergency department (ED) encounter with repair of lacerations. The ED encounter included the following components:
The overall level of history is expanded problem focused. A detailed history would require review of additional systems.
Examination is detailed with an extended examination of the affected body area (right lower extremity) and other related organ system(s) (based on 1995 documentation guidelines).
Medical decision-making (MDM) is low complexity based on a new problem not requiring additional workup after the encounter, review of medical records and immunization history, and decision for minor surgery without identified risk.
An ED visit with an expanded problem-focused history, detailed examination, and low-complexity MDM is reported with code 99282. Modifier 25 is appended to indicate the evaluation and management was significant and separately identifiable from the preservice work of...