99283 w/MOD25

I have a question concerning how to code ER E/M visits. I?m looking at a case where a patient was seen in the ER for an ankle injury. Based on the nurse?s log, the patient was brought to the exam room at 13:25 and was discharged at 14:00. She had two x-rays and was provided an ankle brace. No fracture. Discharge diagnosis was ankle sprain. Does this documentation support a level 3 ER visit? Is the modifier 25 justified? If not, what CPT or NCCI rules would I reference to support the appropriate coding? Please note that the injury happened on 12/10. No other services were provided that day other than those coded below.

845.00 920 305.1 401.9 959.7 V15.59 V58.64 V5869

DOS: 12/10/2014 Rev274 L4360

DOS: 12/10/2014 Rev320 73610-RT

DOS: 12/10/2014 Rev320 73590-RT

DOS: 12/10/2014 Rev450 99283-25



Documentation submitted to support charges are the following.

1) ER Dept Triage: Includes Chief Complaint, Past Med Hx, Past Sx Hx, Risk Screens-Triage Category

2) ER Dept Nursing Record: Neuro, Cognitive, Mental Status, LOC/Total GCS, Coping/Independence, Skin/Extremities/Peripheral Vascular, Respiratory, Cardiac, Gentitournary/Gastrointestinal, Gynecological, Eyes/ENT, Vitals,

3) Medical Screening Examination: First seen by physician 13:30. Documented as emergency.

Chief Complaint: Right ankle/leg injury

Onset/context/duration: Fell when walking down steps and missed one. Twisted her right ankle injuring it and her leg. Struck her left occipital area on railing. No LOC, no neck pain.

Sudden and Constant. Pain scale: Max 7. Pain scale: Now 4. Exacerbation by movement and walking. Relieved by remaining still. Quality is described as pressure and aching.

ROS: Only musculoskeletal, skin, lymphatic, and neurologic documented.

PMH and PSH documented by physician.

Medications reviewed.

Social Hx reviewed.

Nursing Notes were reviewed and vital signs reviewed.

Physical Exam: See nurse?s notes.

Constitutional: Obese, alert, no acute distress, well nourished. HEENT: PERRI, EOM intact, normal conjunctiva and sclera. Normal ENT exam. Hematoma left occipital area. Neck: Normal. Supple. Full range of motion. Respiratory: No respiratory distress. Cardiovascular: NML rate. Pulses full and symmetric. Back: Nontender. Painless ROM. Psychiatric: NML Affect. NML Mood. Neurologic: Alert, oriented x 3. NMI Sensation and motor. Skin: normal color, no rash, warm, dry. Extremity: Affected joint/extremity: right ankle/leg. Tenderness, swelling, and ecchymosis. Normal peripheral neurovaso.

Xray: See footnote #3 (Xray Reports)

ER Course: Discussed xray with patient. Placed in a boot.

DX: See Footnote #4.

Discharged to home 14:00 in stable condition.

99283 w/MOD25