CEDC cheat sheet

Split billing separates the facility component (hospital resources, supplies, nursing, overhead) from the professional component (physician work); each is coded and paid independently.

The emergency department itself is a provider-based department of the hospital; facility ED services are reported with revenue codes and facility E/M levels, not CPT physician codes.

A hospital-based ED physician bills professional E/M codes (99281–99285) with place of service 23 for the ED.

Emergency services require an appropriate medical screening examination under EMTALA regardless of the patient's ability to pay.

Critical care in the ED is reported with 99291/99292 by the physician and a matching facility critical care code; time documentation drives both.

Observation services are facility-level services (G0378 hourly, G0379 direct admission) and are distinct from ED E/M levels.

Facility E/M leveling for the ED commonly uses a hospital-defined point system rather than the CPT MDM or time rules used for professional coding.

Teaching physician documentation rules apply to professional ED coding; the resident's note alone cannot support a professional service.

Trauma team activation is reported with facility codes (e.g., G0390) and is separate from the physician's E/M or critical care code.

ED E/M codes 99281–99285 are selected by medical decision making (MDM) - problems addressed, data reviewed, and risk - not by time.

99281 is self-limited/minor; 99285 requires high MDM and/or a threat to life or bodily function.

The three MDM elements are number and complexity of problems addressed, amount and complexity of data reviewed, and risk of complications/morbidity/mortality.

Two of the three MDM elements must meet or exceed a level to code that level; the highest two determine the level.

Critical care (99291 first 30–74 minutes, 99292 each additional 30 minutes) requires a critically ill or injured patient with high-complexity decision making.

Critical care time includes time devoted to the patient but excludes separately billable procedures and time spent on other patients.

Procedures with a global surgical package (e.g., wound repair, fracture care) do not automatically eliminate the E/M code; a significant, separately identifiable E/M may be reported with modifier 25.

A separately identifiable E/M is documented when the history/exam/MDM is above and beyond the procedure's usual work.

New vs established patient rules do not apply to ED E/M codes; 99281–99285 have no new/established distinction.

Wound repair codes are grouped by complexity: simple (12001–12021), intermediate (12031–12057), and complex (13100–13160).

Repair code selection depends on the total length in centimeters of the wound(s) in the same complexity group and same anatomic site group.

Simple repair includes single-layer closure of superficial wounds; intermediate includes layered closure or extensive cleaning/debridement of heavily contaminated wounds.

Complex repair includes layered closure requiring more than simple or intermediate work, plus scar revision, debridement, or retention sutures.

Multiple wounds in the same complexity group and same site are summed and reported once at the total length; different site groups may be reported separately.

When multiple complexity groups are repaired, report the most complex group first and add modifier 51 to subsequent codes.

Wound repair includes local anesthesia and normal debridement; chemical cautery, electrocautery, and wound exploration may be separately reportable.

Repair codes include the closure of the wound; simple adhesive strips (e.g., Dermabond) for a superficial wound may be reported with 12001 or an appropriate closure code depending on depth.

Debridement codes (11042–11047) are based on surface area (sq cm) and depth (skin/subcutaneous vs muscle/fascia) and are distinct from repair.

Fracture care codes (e.g., 25600–25609, 27500–27514) include the initial evaluation, application of the first cast/splint, and normal follow-up care.

Closed treatment without manipulation (e.g., 25600) is used when the fracture is stable and requires only immobilization.

Closed treatment with manipulation (e.g., 25605) requires documented reduction of a displaced fracture.

Percutaneous pinning (e.g., 25606) and open treatment with internal fixation (e.g., 25607–25609) are reported when the fracture is stabilized with hardware.

Dislocation/subluxation codes (e.g., 23650–23675 for shoulder, 27250–27256 for hip) describe closed or open reduction.

Splint application is included in fracture care when performed at the initial visit; a splint applied without fracture treatment may be reported separately (29105–29131).

A cast or splint applied by a different provider or at a later date may be reported with modifier 58 or as a separate service.

When fracture care is provided and the patient is referred elsewhere for definitive care, the initial service may be reported as an E/M rather than the global fracture code.

Global fracture care is billed once at the initial visit; the global period applies to the fracture code and includes routine follow-up.

Endotracheal intubation (31500) is an emergency procedure reported separately from critical care or ventilation management.

CPR (92950) is reported once per cardiac arrest event; it is not time-based in the same way as critical care.

Mechanical ventilation (94002–94004) is reported by the facility for invasive/noninvasive ventilation; the physician reports the appropriate E/M or critical care code.

Thoracentesis (32400–32405) and chest tube placement (32551) are reported by the physician and include imaging guidance when performed.

Lumbar puncture (62270) is reported separately from the E/M when a significant, separately identifiable service is documented.

Cardioversion (92960 electrical, 92961 internal) is reported per episode; the E/M is separately reportable with modifier 25 when significant.

Central venous catheter placement (36555–36571) is reported by site and type; the E/M is separately reportable with modifier 25.

Pulse oximetry, ECG rhythm strips, and continuous monitoring are typically bundled into the facility ED or critical care service.

Procedures performed on the same day as a major procedure may require modifier 51 or 59 depending on bundling edits (NCCI).

ICD-10-CM codes describe the patient's condition; the first-listed diagnosis should reflect the primary reason for the encounter.

Injuries require an external cause code (V, W, X, Y) to fully describe the mechanism; the injury code is sequenced first, followed by the external cause.

Combination codes (e.g., I50.9 heart failure, E11.9 diabetes) should be used when a single code fully describes the condition.

Signs and symptoms (e.g., R07.9 chest pain, R50.9 fever) are coded when a definitive diagnosis is not established at the encounter.

Laterality (right/left) and encounter type (initial, subsequent, sequela) are required for injury codes.

Sequela codes require the late effect code first, followed by the residual condition code.

Z codes (e.g., Z91.14, Z79.01) capture factors influencing health status and are used when the condition is not the primary reason for the visit.

Unspecified codes should be avoided when documentation supports a more specific code; query the physician if needed.

The ED diagnosis should match the documented final impression or the condition treated; do not code ruled-out conditions as confirmed.

Modifier 25 indicates a significant, separately identifiable E/M service by the same physician on the same day as a procedure.

Modifier 59 indicates a distinct procedural service; it is used to bypass bundling edits when procedures are truly separate.

Modifier 51 indicates multiple procedures; it is appended to additional procedures and typically reduces payment for subsequent procedures.

Modifier 57 indicates an E/M service that resulted in the decision for major surgery (global period of 90 days or more).

NCCI edits define code pairs that cannot be billed together; modifier 59 or an appropriate X modifier may override an edit when documentation supports it.

The X modifiers (XE, XP, XS, XU) are more specific replacements for modifier 59 and are preferred when applicable.

Modifier 76 is used for a repeat procedure by the same physician; modifier 77 for a repeat procedure by another physician.

Modifier 91 is used for repeat laboratory tests; it is not used for repeat E/M services.

Medical necessity and documentation must support every code billed; upcoding or unbundling without documentation is a compliance risk.