Emergency Department Use of Modifiers

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Emergency Department Use of Modifiers

Margaret Pitotti, RHIT, CCS

April 1, 2000, is the start date for using modifiers to report the technical component of hospital outpatient services. Although the Health Care Financing Administration’s (HCFA) September program memo to Medicare fiscal intermediaries (Transmittal A-99-41) clarified many of the areas that will be affected by modifier assignment, several other areas were not directly addressed. One of these is the hospital emergency department (ED).

CODING CORNER Outpatient consultants are finding that while many hospitals assign outpatient modifiers to ED claims (when appropriate), an equal number do not. Part of this omission may arise from an ongoing misunderstanding of the types of outpatient encounters that require CPT and HCPCS procedure code assignment.

Remember: HCFA’s requirement for assigning modifiers to the technical component of hospital outpatient services does include ED services.

As HCFA has advised repeatedly over the last two years, hospitals should already be assigning modifiers. Those who aren’t should begin using them now, so any problems that arise can be addressed before the April 1 effective date.

In addition, hospital managers should take the time to evaluate their outpatient services coding and billing processes, and ensure that the modifiers being assigned, usually by health information management (HIM) department staff, are being reported on field 44 of the UB-92 claim form, next to the CPT or HCPCS code.

In addition to checking these administrative processes, the best way to learn the correct way to assign modifiers is to do it. The sample case studies below address modifier usage in the ED setting and illustrate some of the guidelines of HCFA’s recent transmittal.

Case Study One

Chief Complaint: This 20-year-old, white female is complaining of a burning sensation in her right eye. She thinks there is a foreign body in it. Initially, she thought it was dust. This began two days ago, and she is still having symptoms.

Physical Exam: Vital signs on admission are normal. General exam shows a moderately obese female in no distress with warm, dry skin. HEENT shows that the right eye appears grossly normal. Closer exam reveals a persistent defect in the cornea at about the seven o’clock position between the edge of the pupil and the limbus. The lid eversion is negative, and the anterior chamber is clear.

Procedure: With a slit lamp, I saw the foreign body and removed it easily with an eye spud. There was just a very slight corneal defect without any residual foreign body. It was removed with a moist Q-tip.

Impression: Right corneal foreign body; discharged patient home uneventfully.

CPT Code Assignment: Transmittal A-99-41 provides a list of questions to ask to determine appropriate modifier usage. One of those questions applies to this procedure: Will the modifier add more information regarding the anatomic site of the procedure?

In this case, the answer is “yes”–an answer that supports assignment of the modifier RT (right side).

65222RT Removal of foreign body, external eye; corneal, with slit lamp

Case Study Two

Chief Complaint: Left thumb infection

History of Chief Complaint: This is a 10-year-old, white male who chews his fingernails. An area of erythema and swelling is noted around his left thumb. He has no significant history of trauma and, otherwise, can move his thumb without difficulty. No fevers reported.

Past Medical and Family History: Noncontributory. Social History: Lives with his family. Current Medications: Tylenol. Allergies: None.

Review of Systems: All systems are reviewed and are negative except as mentioned in the history.

Physical Examination: Vital Signs: Temperature 98.4; Pulse 83; Respiration 18; blood pressure 113/69. General: Patient is awake, alert and pleasant. Extremities: The left hand reveals slight erythema around the left thumbnail. There is no evidence of pus under the nail. The pad of the finger is somewhat swollen and erythematous, but there is no tenderness to palpation along the flexor tendon. He can flex and extend the thumb without difficulty.

ED Course: A digital block was performed with 1% lidocaine. A #11 blade scalpel was used to incise the eponechyea and parenchyma to the lateral aspect of the thumb as well. Several cc of purulent drainage was excised.

The wound was irrigated and dressed with sterile dressing. Will also treat with antibiotics for possible felon. Mother understands that if there is no improvement, the patient will need an X-ray to rule out osteomyelitis.

Impression: Parenchyma and possible early felon.

Plan: Patient is discharged home in good condition. Follow up with primary care physician on Monday for wound check. Return to ED if symptoms worsen. Warm water soaks with peroxide b.i.d. Prescrip-tion is given for Keflex.

CPT Code Assignment: In this case, level II modifier FA–left hand, thumb–may be used to add specificity to the procedure performed on fingers.

26010FA Drainage of finger abscess; simple

Margaret Pitotti, a senior health care consultant with Medical Learning Inc., St. Paul, MN, has 23 years of experience in inpatient and outpatient coding.

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