ED Coding and Reimbursement Alert

by Caral Edelberg
ECA Consulting Editor

Editors Note: In this issue of ED Coding Alert, we introduce a new feature: the case study. In this and upcoming issues, we will take a typical patient chart or specific coding dilemma and guide readers through a step-by-step decision-making process to arrive at a solution. If you have a case study you would like to submit for consideration, please fax to 800/508-2592.

No matter how many coding guides, supplements and resources you collect, it seems there are always coding dilemmas that just wont fit neatly into the scenarios described in CPT or presented in the coding seminar your entire department just attended.

In this column, we will examine the case of a motor-vehicle accident (MVA) victim who presents to the ED with multiple lacerations. We will discuss the process taken to arrive at the proper evaluation and management (E/M) level to be coded and recommend which procedure codes should be used. (Please refer to the patient chart at right for the available documentation.)

Coding Discussion

First, remember that the primary function of coding is to translate the available documentation into the accurate codes. When in doubt, a coder has two options: seek additional clarification from the provider; or, code from the documentation as is. The latter choice often results in a bill coded for a lower level of service than may have been provided. However, a good coder never assumes that a service was provided by trying to read into the documentation when no supporting evidence exists. When all is said and done, the information provided on the medical record is the only existing verification of the content and extent of the service that was performed.

This case presents a challenge to the alert ED coder for a number of reasons. Initially, this patient presents as the victim of an automobile accident where the patient, as driver of the vehicle, sustained facial trauma. To the coder, this should be an immediate indication of the potential for additional injuries. These could be identified in order to qualify for an E/M level higher than is justified by just the surgical repair of the lacerations alone.

The level of E/M service is scored by identifying the components of the history, physical exam and medical decision-making documented by the physician. The components of the E/M are then compared to the types of laceration repair performed to determine what components of the E/M are considered part of the surgical package.
Scoring the History of Present Illness (HPI)

The physician in this case has provided clear information relating to three elements of the HPI: location (face, mouth, lips); context (unrestrained driver, motor vehicle accident [MVA]); and duration (prior to arrival).

Level of HPI: Brief

Scoring the Review of Systems (ROS)

Review of the entire history statement provides us with two reviewed systems. However, the physician indicates a negative ROS. At a minimum, in this case, we would expect to see positive responses to the systems related to the chief complaint. (The HPI indicates multiple lacerations). Thus, we know that at least one system is positive for injurythe skin. We can use the no LOC (loss of consciousness) statement in the HPI as a negative response to the neurological ROS.

Under the best of circumstances, the physician should have individually listed the pertinent systems as reviewed, and recorded the patients response, then followed that by writing all other systems reviewed and negative for systems that are not pertinent. However, with this ROS, the physician recorded negative to all systems so it is difficult to know just how many were actually reviewed. As a default, we have scored the systems referenced in the HPI statement.

Note: According to HCFA guidelines a statement may be used only once: to qualify for elements within the HPI, or to score elements of the HPI and ROS. In this case, multiple references were made to the facial lacerations in the HPI so we can comfortably use them to score both the HPI and the ROS.
Level of ROS: Extended (2-9 systems)

Scoring the Past, Family and Social
History (PFSH)

The physician states that there is no past medical history and refers to the nursing notes which indicate allergies and no medications. There is no social history or family history recorded.

Level of PFSH: Detailed

Overall Level of History Recorded: Expanded Problem Focused

Note: With the recording of one additional element of the HPI, this history would have scored at the
detailed level.

Scoring the Physical Examination

The physician addresses an examination of the following body areas and organ systems: Body areas: neck, chest, abdomen, extremities (4). Organ systems: eyes, ENT, skin, neurologic, psychiatric.

Note: We are using the 1995 documentation guidelines to score the level of physical examination because, in this case, the 1998 physical examination requirements would result in a lower level of service.

Level of Physical Examination: Seven body areas (including each extremity as one) and five organ systems have been identified; this qualifies as a detailed physical examination (5-7 body areas/organ systems). Although the number of body areas and organ systems reviewed exceeds the 5-7 requirement for a detailed exam, coding to the next level would require the examination of eight or more organ systems.

Scoring the Medical Decision-Making (MDM)

There are three areas of evaluation to consider when assigning an overall level of medical decision-making: the amount and complexity of data or tests reviewed; the number of diagnoses and/or management options; and the amount of risk to the patient. In this case, they are as follows:

1. Amount of Data or Tests Reviewed. There were no tests or records ordered or reviewed.
Level Assigned: Minimal

2. Number of Diagnoses and/or Management
Options. This is a new problem with multiple management issues necessitated by the traumatic injury to the head, the multiple lacerations requiring treatment, and the potential for other injuries as indicated by the level of physical examination.
Level Assigned: Moderate

3. Risk. The presenting problem is moderate due to the multiple injuries; the diagnostic procedures ordered is minimal as there are none indicated; and the risk is moderate due to the minor surgery required and the prescription drug management required.
Level Assigned: Moderate

The moderate level of medical decision-making is an accurate indicator of the overall level of acuity managed by the emergency physician. However, the omission of the one element of the HPI resulted in scoring this case at the expanded problem focused level which is the lower of the history, physical examination and MDM. This is a common problem in emergency medicine codingthe physician fails to record the history and/or physical examination consistent with the level of medical decision-making. When this occurs, coders should provide necessary feedback to physicians to assure that unnecessary downcoding is minimized.

As this is not a Medicare patient, one can debate whether the documentation guidelines apply in this case. In referring to the content of the E/M codes published in CPT, no mention is made of the numeric equivalents of the E/M components, which leaves the actual content open to much speculation. Each payers interpretation of coding rules obviously plays a significant role in how codes are selected. There is no simple solution, however.

Overall E/M Level Assigned: 99283 - Expanded Problem-Focused

Choosing the Procedure Codes

Three lacerations were identified:

Wound No. 1 is a through-and-through laceration below the lower lip closed with 5-0 vicryl to subcutaneous layer, 6-0 ethilon for skin.

Wound No. 2 is a 5-cm c-shaped (through and through) laceration to the mucosal side of lower lip with reference to exploration and anesthesia but no reference to the actual closure.

Wound No. 3 is 1.5-cm superficial laceration to the upper lip closed with 5-0 vicryl.

Although three wounds have been identified and treated, the documentation of wound size and evidence of treatment for all is incomplete. The documentation for wound No. 1 omits the length of the laceration, and wound No. 2 omits reference to the actual repair. For wound No. 1, the lowest level of layered repair of lip (2.5 cm or less) can be coded. However, wound No. 2 presents a more significant problemone can not assume that the wound was repaired by the emergency physician, even though all indications are that it was. If the coder is not able to obtain an addendum to the record from the physician documenting the actual repair, then this wound repair must be omitted from the coding.

Many physicians do not understand the significant constraints placed on coders who must follow the coding rules while attempting to convert poorly or illegibly documented services correctly. Assumption coding has drawn the attention of the OIG and is specifically referenced in the recently published compliance guidance. Coders and physicians are well advised to avoid the expectation that services not clearly documented can be coded. The physician ultimately benefits when the coder minimizes the risk by coding appropriately.

We chose the following laceration codes:

Wound No. 112051 layer closure lip
Wound No. 2No code due to lack of documentation
Wound No. 312011 simple closure face

Final Code Recommendation

ICD-9 Codes

873.43 open wound of head, lip.
873.60 open wound head, internal structures
of mouth.
873.49 other and multiple sites face.
E812.0 other motor vehicle traffic accident involving collision with motor vehicle.

CPT Codes

99283-25 Expanded problem focused E/M service. The
-25 modifier indicates procedures performed on the same day and same patient, by the same physician.
12051* Layered closure of wounds of face, lips and/or mucous membranes, 2.5 cm or less.
12011* Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes, 2.5 cm or less.

Note: Each of the laceration repairs are starred procedures. As such for this non-Medicare payer, they only define the direct operative service. All preoperative and postoperative service provided by the emergency physician will be identified with the appropriate E/M service level as outlined in CPT. Medicare combines all directly related pre- and postoperative service with the intra-operative service. Thus, if this were a Medicare patient, the service performed over and above the direct preoperative care for each procedure would be identified with an E/M service code.

Other Interpretations Possible

You must remember that individual state and carrier guidelines may alter the way you would code this case. Coding is not an exact processthe nuances and alternatives are varied from one state, one payer or one locale to another. The cases discussed in this column present one interpretation of the available documentation. The final solution in your area will depend on your payers coding rules developed through their unique interpretation of available guidelines.