ED Coding and Reimbursement Alert

Signs-and-symptoms coding holds key to solid claims

If your ED physician diagnoses a sickle-cell patient with acute chest syndrome (ACS, 517.3), you'll need to know how to code initial exams, such as x-rays and bone scans, along with signs and symptoms.

Although ACS strikes many sickle-cell patients, the physician may run a variety of tests to ensure the patient doesn't have another respiratory problem, such as pneumonia (480.x, Viral pneumonia).

Example: A sickle-cell disease (282.6x) patient presents to the ED with shortness of breath (786.05), chest pain (786.5x), difficulty breathing (786.09, Respiratory distress), and fever (780.6).

The physician obtains a comprehensive history and performs a comprehensive exam, which includes reviewing all organ systems. Then he orders and interprets x-rays, which show some abnormalities (793.1, Nonspecific abnormal findings; lung field).

The physician may also review sputum results (89220, Sputum, obtaining specimen, aerosol-induced technique [separate procedure]) and bone scans (78300, Bone and/or joint imaging; limited area), says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. Generally, you should include the review of the sputum analysis and bone scans with the evaluation and management service. The facility that owns the equipment would report 78300 (bone scan).

How you code the x-ray services depends on who performs the work and reads the films. If the physician owns the equipment, you can report the global radiological code, such as 71020 (Radiologic examination, chest, two views, frontal and lateral). This code includes both technical and professional components.

Be sure to link the above signs and symptoms, such as chest pain (786.5x) and rib cage tenderness (786.59, Chest pain; other), to 71020, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

But if a radiologist performs the x-ray and interprets the films, the ED physician can't report 71020. If, however, the ED physician ordered a report and reviewed the radiologist's findings, you may consider this a component of medical decision-making in the E/M code.

If the physician performed a comprehensive history and exam and engaged in high-complexity decision-making, you may report the appropriate E/M code (in this case, 99285).

Helpful: Physician documentation should include notes of all the work he performed, such as reviewing x-rays and examining all the body systems, to justify the level of E/M service.

After the physician diagnoses a patient with ACS, don't let all of his care go to waste by listing 517.3 (Acute chest syndrome) as the primary condition. To medically justify services, you should list an ICD-9 code for sickle-cell disease in crisis, such as 282.42 (Sickle-cell thalassemia with crisis), as the primary condition, and then use 517.3, according to ICD-9 guidelines.