# Regional Trauma Center professional services coding



## bill2doc (Nov 30, 2011)

Does anyone know of any good web classes for trauma billing?  I am getting so confused and frustrated with my trauma doctors and trying to do their billing.  I explained that an auto accident patient coming into trauma for abdominal pain does not warrant a 99291 critical care CPT.  The Chief of Trauma is telling me that the difference in my inpatient doc's who do critical care is that they already have the patient diagnosis of Resp Failure or Renal Failure etc.  He said in a patient coming in for the above case, abdominal pain would be the exact reason the patient would get a full work up and because they are the Regional Trauma Center and spend a lot of time to figure out what is wrong with the patient the coding is different and I should be billing for critical care.....  Can you see why I'm confused.  I need intervention fast.  Is there anyone coding for professional service at a Trauma Center? Maybe I can fax an op report and get an opinion of what I would code?

Or I can just type out the report just as I see it ....


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## mdoyle53 (Dec 1, 2011)

It should be very simple - the guidelines state - "A critical illness or injury actually impairs one or more vital organ systems such that there is a high probability or intermittent or life threatening deterioration in the patient's condition".  Ask the physician which organ system meets this requirement and where it is documented in the note!!

I have done ER coding for a group that has multiple hospitals they service, although not trauma center, and it is absolutely rate they will bill 99291.

Just because you are in a trauma center, you cannot ignore the guidelines or you will 'pass go and not collect the money and go directly to jail'.  Just ask them if it is worth their license.


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## bill2doc (Dec 1, 2011)

Exactly - I have been pushing back so hard.  I don't know where this thought process is coming from except that maybe its "activated as a trauma" per their notes... Thanks for your reply. I do hope I get more opinions so I can have lots of back up to my position.


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## mitchellde (Dec 1, 2011)

Try this, There are times when yes a patient needs to be worked up first and then it is discovered that they are in fact critical and in danger of loss of life or limb... it happens even with non trauma.. You can bill both a regular ER level and critical care if the documentation supports it.  So you can have a regular assessment and then the trauma doc says patient is stable.. so good nothing more there... or he could say the patient has liver damage or renal or whatever and then critical care notes start.  This is the way our trauma docs do it and it works very well.  They only do this for patients that arrive that do not at first look appear obviously critical.  They always have two separate notes when this happens and note the time of the start of critical care.  It has worked great so you might try that approach.


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## bill2doc (Dec 1, 2011)

I think my doc are banking on the "patient deterioration - not death - is imminent.  Deterioration can be somewhat based on interpretation.  In most of my cases, there is not a trauma doc coming to advise of damage after the fact.  They are the first docs to see the patient and they assessment does not warrrany critical as defined unles you consider the magic word Deterioration....


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## Mojo (Dec 1, 2011)

Bill, have any of these questionable "critical care" visits involved interventions to prevent imminent or life-threatening deterioration such as fluid resuscitation, vasopressors, mechanical ventilation, gastric lavage, transfusions...?

I assign 99291 when the criticality of the patient, the intervention and 30 minutes of full attention to patient care (exclusive of the time for separately reportable procedures) have been documented.


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## mitchellde (Dec 1, 2011)

but they have to have actual patient deterioration not the anticipation of it before critical care engages. It sounds like you are going to run uphill on this one.


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## mdoyle53 (Dec 2, 2011)

The medical intervention is just fine but if the reason for it is due to deterioration of the patient and a potential life threatening situation, then it is critical care; otherwise it is not.  Critical care is very plain and simple - show me the impairment of the system or one that will have deterioration and then show me the intervention to prevent, etc. - if not, then it is not critical care.

As far as billing an ER and then CC - Medicare does not allow this but some insurance carriers do.  

I would be cautious to make sure they are definitely separated and identifiable.  The time and effort on the EM would not be usable for the critical care - sooo be careful.


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## jimbo1231 (Dec 4, 2011)

*Trauma Related abdominal Pain*

Bill 2,

I'm just wondering what type of trauma caused the abdominal pain, how severe it was, addtional symptoms etc. When patient's come to the ED with Abdominal pain it is typically a medical condition and seldom CC. But car accident induced abdominal pain could be life threatening....say a potential ruptured spleen etc. But this would require clear documentation of what happened, the interventions, diagnostics, differentials etc. As well of course ot the CC time. I agree with everyone that simply abdominal pain doesn't look like CC even in a trauma center. But other documented factors might justify CC.

Jim


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## bill2doc (Dec 6, 2011)

Jim,

I get a lot of found down, and Auto accident.  I can't find my Abdominal Pain but let you send you another that I feel is 99284 but noted as Critical Care.  Maybe you all would think this is more of a 99283 or 99285 ??

REPORT TITLE: Trauma and Critical Care Sugery Consultation
CHIEF COMPLAINT: Status post motor vehicle collison
PERTINENT TRAUMA CRITERIA: The patient was deemed to meet trauma activation criteria and was activated as a code trauma. The pt was brought to the Medical Center as the regional trauma center and I was summoned to see the pt as the trauma surgeon on duty and was there to perform the emergency assessment trauma evaluation and critical care management according to the Americal college of Surgeons Advanced Trauma Life Support Protocol. The eval on this pt on an emergency basis is mandated by state and federal law as well as by the county and our trauma emergency department. The Americal College of Surgeons advanced trauma life support protocol was followed in the eval, trauma management, and critical care of this patient.
HISTORY OF PRESENT ILLNESS: The pt is a male who was restrained driver in a motor vehicle collison. He had no loss of consciousness but was complaining of left hand and knee pain. He was activated as a code trauma and arrived by ambulance at 0:00 am on _/_/11.  In accordance to the Americal college of surgeons advanced trauma life support protocol, I initiated my primary survey
PARAMEDICA REPORT:
PRIMARY SURVEY A.AIRWAY Airwary was open adn patent B.BREATHING pt breathing spontaneously w/o paradoxical chest wall motion. C. CIRCULATION pt had warm palpable pulses and brisk capillary refill in all four extremities D. DEFORMITY AND DISABILITY pt had no evidence of long bone or gross body torso deformity E EXPOSURE pt clothes were removed almost entirely and there were no signs of open hemorrhagic lacerations.
GENERAL ASSESSMENT The patient was awake, alert and oriented x3, and had a Glasgow Coma Score of 15. His memory was intact. The pt was able to give me the following past medical history
Chronic Medical disease - none, past surgical history - none, Medications - none, Allergies - None, family history noncontributory
SOCIAL HISTORY Tobacco Use - Denies, Alcohol Use - Denies, Illicit Drug use - Denies
TETANUS TOXOID STATUS  up-to-date
REVIEW OF SYSTEMS: Left hand pain
PHYSICAL EXAMINATION AND SECONDAY SURVEY
GENERAL well developed, well nourished male who apprears to be stated age
VITAL SIGNS initial vital signs were blood pressure 120/80, pulse 86, respirations 18 temperature 99
HEAD head examined and found w/o signs of lacerations, abrasions or contusions
EYES pupils were equal, round reactive. sclerae were not icteric. extraocular muscles were intact, good visual acuity
EARS external auditory canals clear no signs of hemotympanum bilaterally, not signs of tympanic membrame injuty no signs of external ear lacerations, abrasions or contusions
POSTERIOR CERVICAL SPINE: The posterior cervical spine was palpated w/o signs of tenderness. The was no bony step-off or crepitus on palpation
ANTERIOR MID-FACE mid face w/o bony step off or lacerations, abrasions or contusions
NOSE Nose w/o signs of nasal septal deviation. No signs of nasal septal hematoma and no signs of rhinorrhea nasal passages w/o lacerations, abrasions or contusions
ORAL CAVITY: Oral cavity w/o signs of lacerations, abrasions, or contusions. No signs of tooth loss or injury
MANDIBLE: mandible was nontender w/o palpable bony deformity. normal occlusion on mandibular bite down technique
ANTERIOR NECK Anterior neck was w/o crepitance. The trachea was in the midline. There were no stridor sounds upon respiration. No distention of the neck veins.  No sign of Laceration, abrasions or conusions
ANTERIOR CHEST The chest was clear w/ good breath sounds bilaterally, no wheezes, no rales, no rhonchi no lacerations, abrasions or contusions
HEART heart regular rate and rhythm, no auscultated murmur gallop or rub. no faint or muffled heart sound
ABDOMEN abdomen was non tender, no rebound no guarding no peritoneal signs. no rigidity no distention no lacerations, abrasions or contusions
PELVIS Pelvis was stable upon rocking motion w/o bony step off or crepitance no lacerations, abrasions or contusions
EXTREMITIES The extremities were w/o signs of clubbing, cyanosis, or edema. Pt good palpable pulsesand brisk capillary refill in all four extremities. moved all 10 fingers and woes w/o limitation. Good sensation to light touch and had no pain in all four extremities. There were no signs of lacerations, abrasions or contusions. There multiple small avulsions that are less than 1 cm in length on the left knee and the dorsal aspect of the left hand. No other lesions, lacerations or contusions were noted.
BACK The back was w/o palpable bony deformity on palpation of the entire thoracolumbosacral spine.  There was no evidence of lacerations, abrasions or contusions. There was no pain or discomfort on percussion of the costovertebral angles bilaterally
GENITAL/RECTAL external genital and rectal areas were w/o signs of bloddy discharge
NEUROLOGIC Cranial nerves were evaluated, and cranial nerves ____XII were grossly intact.
LABORATORY STUDIES
Hematology white cell 4.3, Hemoglobin and hematocrit of 15.0 and 41.7 platelets 207
Chemistry Soduim 139 potassium 3.5,chloride 103 co2 of 26 bun of 18 creatinine 1.5 glucose of 84 calcium 9.0
Blood alcohol zero
RADIOLOGIC STUDIES Chest xray upright i snegative for intrathoracis trauma
Misc radiologic studies Plain film of left hand in neg for fracture or dislocation. Plain film of left knee is neg for fracute or dislocation
ANALYSIS AND PLAN


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## bill2doc (Dec 6, 2011)

ANALYSIS AND PLAN/INPRESSION AND PLAN: status post motor vehicle collision with no loss of consciousness, and only a small avulsion to the hand and knee with no evidence of bony or organ injury. His cervical spine as cleared by clinical criteria. There were no indications for outside consultation regarding the care of this patient. He was observed in the trauma bay and when met discharge criteria he was was allowed to return home with instructions for close follow up

TOTAL TRAUMA AND CRITICAL CARE TIME : 1 HOUR AND 2 MINUTES


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## FTessaBartels (Dec 9, 2011)

*MDM is Low*

He has two new problems w/ workup so get 4+ problem points
Both labs and X-rays ordered so 1 data point for each = 2 data points (NOTE - I can't tell from this note if the doctor personally reviewed the Xrays, so not giving him those points.)
I get a Low Risk for an acute uncomplicated illness or injury

This adds to LOW MDM  Which means the most he can get is 99282
If he actually reviewed the X-rays, then it bumps his data points to 3 and the MDM to Moderate. 

The patient is NOT critically ill.  I believe that the physician felt it medically necessary to perform that full exam / work-up to check for injuries, but that does not mean the patient is critically ill and that the service provided is critical care. 

Then there's the history .... at best he has an EPF history with a chief complaint, 3 elements of HPI (context, location and duration) and 1 ROS (no loss of consciousness).
I suppose I *might *count the paramedic's report as ROS ... in which case I would give 4 elements of HPI (context, location, duration and assoc signs), and extended ROS for the Paramedics survey of resp, cardio and musculoskeletal; and then the patient's past medical history and social history  (family history noncontributory does not count for anything).  So if I were feeling generous I'd give him a DETAILED history.

So IF his MDM were moderate we could code 99283.  But as it stands this is a 99282.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## jimbo1231 (Dec 10, 2011)

*No CC*

I see nothing on that chart that would indicate CC. In fact I don't think you have a 4 due to lack of history.
All the official language about referral to Trauma Center looks good but your doc has to undersatnd that it has nothing to do with coding guidelines.
I do work for mostly ED docs and if anything they land on the opposite side, underdervaluing CC services and time.I also do some work for Trauma Surgeons and I think you are dealing a bit with surgeon ego. I think what you can do is review CC guidelines with the doc. And it wouldn't hurt to also revew E&M.

Jim


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## bill2doc (Dec 12, 2011)

Thanks to you both.  Jim, you are correct.  I'm having a hard time getting through to them...I hope I can reach out to you in the future.  You are billing exactly what they are asking me to do and I'm GREEN

Thanks so much
Lynn


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