05/01/2017

E&M for ER Gas Gangrene & Billing for Transmet Amputation Partial Metatarsals (2nd, 3rd, 4th and 5th)

A new pt was seen in the ER for gas gangrene. The pt was then brought to the O.R. where the 2,3,4,5 toes were amputated as were part of the 2nd, 3rd, 4th, 5th metatarsals. What is the proper series of E&M for ER are used, and what is the proper way to bill for the procedure rendered as to me a transmet amp would include all metatarsals and the first ray wasn't touched...?

The E&M code would depend where the patient was seen in the hospital before the decision for surgery was made- if the visit was done in the ER, one of the following codes should be reported:

• 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor.)
• 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity.)
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.)
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.)
• 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.)

Modifier -57 should be appended to the E&M code billed so the visit does not deny as global to the surgery that will be billed subsequently.

The correct amputation code that should be billed for an amputation of both the toe and metatarsal bone is CPT 28810 (Amputation, metatarsal, with toe, single). For each digit that is amputated, this code should be reported on the claim, or four lines. The only modifiers required are -T modifiers for the toes affected (-T1, -T2, -T3, and -T4 if the surgery was done on the left foot, -T6, -T7, -T8, and -T9 if performed on the right foot).