ED Coding and Reimbursement Alert

ED physicians unfamiliar with proper coding for trauma often undercode and undercharge for these services. But often a third-party payer, such as an automobile insurer or workers' compensation carrier, is responsible for payment. No matter who is paying the bill, full compensation is lost unless all separately billable procedures are documented, says David McKenzie, director of the reimbursement department for the American College of Emergency Physicians. "If you're not billing for these, you're leaving money on the table," McKenzie says.
 
Mike Williams, president of the Abaris Group in Walnut Creek, Calif., who has spent nearly 10 years educating ED physicians and coders on how to turn their trauma units around, says financial stress comes from improper coding and not knowing where to collect the fees. For instance, many times trauma patients in motor-vehicle accidents (MVA) have automobile insurance on top of their regular medical insurance. Sometimes trauma cases are work-related, so workers' compensation claims must be filed. "If you charge and bill trauma correctly, there is potential for a significant source of revenue," he says.
 
Lorraine Began, CPC, billing compliance monitor for the Metrohealth System in Cleveland, says her coders refer to a "cheat sheet" when reviewing documentation for a trauma case. The list includes most procedures that can be billed separately for trauma. Some of the treatments include CPR (92950), cardioversion (92960), thoracotomy (32160-54), pericardiotomy (33020-54), endotracheal intubation (31500), tube thoracotomy (32020-54), cricothyrotomy, thoracentesis (32000*), pericardiocentesis (33010), peritoneal lavage or DPL (49080*), transcutaneous pacemaker (92953), transvenous pacemaker (33210), ventilator (94656), transfusion (36430) and therapeutic phlebotomy (99195). Of course, other procedures, such as lacerations, casting/strapping and fracture care, also qualify as separately billable.

 
One example of billing for additional services beyond E/M with a trauma patient might include laceration repairs.  For example, an MVA patient presents to the ED with a laceration on the left forearm, and head trauma. The patient is alert on arrival but was unconscious when the emergency medical services (EMS) arrived at the scene. The ED physician examines the patient to determine if any other injuries exist and orders x-rays to rule out fractures or internal injuries. A CAT scan is ordered because the patient had lost consciousness. The ED physician's documentation must support the level of E/M service and whether the patient fits into critical care.
 
Because the patient is alert and briefly lost consciousness, the ED physician performs a comprehensive history and physical examination and codes the case 99285 (emergency department visit for the evaluation and management of a patient, which requires a comprehensive history; a comprehensive examination; and medical decision making of high complexity). However, to be compensated for any other procedures the physician performs, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) must be appended to the E/M code.
 
The ED physician then examines the forearm wound, determines a single-layer closure is needed, and documents a 2.7-cm laceration to the forearm. The documentation describes irrigation to the wound and closure. The physician reports CPT code 12002 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm). By attaching modifier -25 to the E/M 99285, the E/M service is designated as a significant, separately identifiable service as indicated by the need for a more extensive history and examination of other potential injuries and the head CT scan ordered to rule out head trauma.

Modifier -54
  
An MVA patient presents to the ED with head trauma and a minor fracture of the finger that does not require intervention by an orthopedist. The ED examines the patient to determine if any other injuries exist and -- to rule out fractures or internal injuries -- orders x-rays.  Following a detailed history and exam, the ED physician determines a level-four (99284) service. The physician's documentation, of course, must support the E/M level. 
 
Assessment of the finger injury indicates no displacement, 26600 (closed treatment of metacarpal fracture, single; without manipulation, each bone). The finger must be stabilized so it can heal. The ED physician performs the stabilization and places a splint on the finger. The fracture code 26600 also needs  modifier -54 (surgical care only) to indicate that the ED physician performed the restorative treatment, or the bulk of the work, but will not handle the follow-up. The primary care physician or orthopedist usually follows up on fractures. 

 

 
A patient presents to the ED with head and abdominal injuries from a head-on collision. The ED physician might order x-rays and CAT scans as in the above scenarios and also perform a diagnostic peritoneal lavage (DPL), 49080*, because the patient complains of stomach pain. The DPL provides a quick screening for intraperitoneal blood. A positive DPL means a need for surgery, and the patient is transported to the operating room. In this case, the ED physician documentation supports a 99285-25 with 49080* separately billed.

 

For ED or critical-care codes, Williams emphasizes the importance of physicians and coders remembering to attach the appropriate modifier and log all procedures performed.
 
McKenzie says many facilities have a team of trauma specialists or trauma units. When a patient presents to the ED with blunt or penetrating trauma (e.g., stab wounds and gunshots), you would typically bill a lower-level E/M service if the patient is immediately transported to the  trauma unit or if the specialist team is called in.
 

But if trauma is handled solely in the ED, physicians must know which level of E/M to assign. Williams says that often ED physicians limit themselves to using ED E/M codes when critical-care codes (99291, 99292) might be more applicable. "The new, more relaxed and global definition of critical care now affords ED physicians easier access to these codes," he says.
 
For example, an MVA patient presenting to the ED with a ruptured spleen could qualify as critical care, but often the ED physician miscodes by using an E/M level three, four or five. If physicians neglect to report all the separate procedures, they lose out on even more income.
 
According to the 2001 Medicare RBRVS Physician Fee Schedule, the physician work relative value unit (RVU) for an ED level-five service (99285) is 3.06. Critical care, in comparison, has a physician work RVU of 4.0 for the first 30 to 74 minutes.