ED Coding and Reimbursement Alert

by Caral Edelberg,CPC
Consulting Editor

Coders are frequently challenged to code for orthopedic procedures performed in the ED by the emergency physician. Depending on the extent of the injury, the experience of the emergency physician, and the sophistication of available technology, the physician may either treat the patient in the department, call in an orthopedist to treat the patient, or stabilize the patient and refer to an orthpedic specialist outside the ED for timely follow-up. The codes applied will vary greatly depending on which situation occurs.

Note: For more information on reporting orthopedic codes in the ED, see the article Use Orthopedic Codes Plus Modifier -54 to Get Paid for ED Fracture Care, page 3 of ED Coding Alert, December 1998.

This months case illustrates the importance of understanding the clinical limits of the emergency physicians involvement in treating orthopedic injuries, using an example of a patient who presents in the department after a fall down a flight of stairs (see sample patient chart on page 53).

Choosing a Version of E/M Documentation Guidelines

With the evaluation and management documentation guidelines in a state of fluxphysicians may use either the 1995 or the 1997 version of the CPT manualassigning a level to the physical exam involving two or more body areas or organ systems can be very confusing. Most physicians and coders agree that the 1995 version is the least burdensome. However, the introduction of the proposed bulleted format in the 1997 version caused confusion about what auditors consider acceptable documentation.

The 1997 set of guidelines differentiates body areas (e.g., head, neck, abdomen, genital/groin/buttocks, extremities, and back) from organ systems (e.g., constitutional, eyes, ENMT, respiratory, CV, GI, GU, musculoskeletal, hematologic/ immunologic/lymphatic).

For a 99285 (comprehensive examination) E/M level under the 1995 guidelines, HCFA specifically requires examination of organ systems (rather than body areas) and also states that a comprehensive exam is a complete exam of a systemnot (continued on next page) just a brief statement about that system.

There is no clarification within the 1995 guidelines that defines the difference between: 1) a body area and an organ system; or 2) what constitutes a comprehensive examination.

In this case, we have used the 1995 documentation guideline requirements to assign the level of physical exam, but also have mentioned which documentation provided by the physician also might be used to determine the content of the exam or differentiate an organ system from a body area using the 1997 criteria.

Scoring the History and Physical

The patient sustains multiple injuries in a fall and is transported to the ED via ambulance. Evaluating the physician documentation using the 1995 documentation guidelines, we assign levels to the history of present illness (HPI), review of systems (ROS), past, family, and social history (PFSH), and physical exam to determine the level of service.

1. Scoring the HPI. The following elements of the HPI were recorded by the physician: context (fell down stairs); duration (just prior to arrival); location (right upper extremity, left knee, left ankle); associated signs and symptoms (denied other injuries as specified).

Level of HPI: Extended

2. Scoring the ROS. The statement negative for chronic illness or conditions other than some osteoarthritis and hypertension could be considered as relative to the conditions related in the HPI with all other systems negative.

Level of ROS: Complete

3. Scoring the PFSH. Social history is referenced, but no other history element is recorded that could be utilized as either past medical or family. All other elements have been used as other components of the history.

Level of PFSH: Pertinent
Overall level of History Selected: Extended

4. Scoring the Physical Examination. Ten organ systems were examined and recorded: constitutional, cardiovascular, respiratory, GU, neuro, eyes, ENMT, musculoskeletal, skin and psychiatric. Additional body areas detailed in the physical examination documentation included face, back, neck, abdomen and four extremities, but all are included in their related organ-system examinations.

Level of Physical Examination: Comprehensive

Scoring the Level of Medical Decision-Making (MDM)

Documentation of MDM for this patient is primarily found in the treatment plan for the diagnosed orthopedic injuries. Injury No. 1, a right-elbow posterior dislocation, is reduced by the emergency physician without anesthesia. Post-reduction x-rays reveal correction of the dislocation.

Note: There is no indication that the emergency physician actually interpreted the x-rays, so no charge can be made for an interpretation.

Injury No. 2, the radial head fracture, is diagnosed by the emergency physician but not treated. Instead, the emergency physician refers the patient to an orthopedist within one day. The patient is held in the emergency department for observation following treatment to assure there is no neurovascular compromise.

The following splints are applied: a plaster splint on the right upper extremity, and soft knee-and-ankle splints to the left lower extremity.

1. Number of diagnoses or management options. This patient had multiple injuries requiring individual treatment.

Level assigned: Extensive

2. Amount and/or complexity of data reviewed. X-rays (number unknown) ordered and reviewed; no other data indicated.

Level assigned: Minimal/none

3. Risk. Multiple injuries requiring ED management and referral for further treatment. However, no indication that any are life- or limb- threatening.

Level assigned: Moderate
Overall Level of MDM: Moderate
Overall Level of E/M: 99284-Detailed

Choosing the Right Procedure Codes

A level 4 E/M code (99284) is supported by the physicians documentation of the total service. And, because a separate orthopedic surgical procedure was performed on the same day,
a modifier -57 (decision for surgery) should be applied to the E/M code.

Note: The modifier -57 is generally billed when non-starred, global surgery procedures are billed in addition to an E/M level. In some cases, the -25 modifier (significant, separately identifiable procedure by the same physician on the same day) would be preferred by payers to indicate the E/M service was significant, separate and distinct from the surgical service.

The coder should also report an orthopedic code for the repair of the elbow dislocation (24600, treatment of closed elbow dislocation, without anesthesia) because the emergency physician performed the restorative care for the injurythe reductionin the ED.

However, the dislocated elbow will require follow-up treatment with an orthopedic specialist (to evaluate the healing of the elbow and decide about the removal of splint). Orthopedic codes are global surgical codes that include all pre- and postoperative care. Therefore, if the ED coder reports the code for treatment, a -54 modifier (surgical care only) must be applied to the orthopedic code to indicate that the ED physician is providing the preoperative and operative care only, and postoperative care will be provided by another physician.
The plaster splint on the upper extremity would also not be separately identifiable because its application is included in the global surgical package.

The radial head fracture, injury No. 2, cannot be reported with an orthopedic code because the ED physician only diagnosed the injury and referred the patient for follow-up with an orthopedic specialist within 24 hours. The physician service for this is included in the level 4 E/M code.

Treatment of the contusions to the left knee and ankle consist of the splint application, which would normally be billed separately, but are not in this case, due to the lack of physician documentation.

The physician should also report a 99288 (physician direction of EMS). The record indicates that radio control was established en route and may be billed if the record contains the documentation of the ED physicians management of treatment in the field.

Note: Medicare does not reimburse for this service, however, private payers generally do. It is best to research individual payer policy regarding content of documentation and payment policies prior to using 99288.

Final Code Recommendations

CPT Codes

99284-57 Level 4 E/M service (decision for surgery)

99288 Physician direction of EMS

24600-54 Elbow dislocation (pre- and operative service only)

ICD-9 Codes

832.02 Posterior dislocation of the elbow,
closed dislocation

813.05 Fracture of radial head

924.11 Contusion of knee

924.21 Contusion of ankle

E880.9 Fall from stairs or steps