ED Coding and Reimbursement Alert

Treatment doesn't always include exploration

When a patient presents in the ED with a wound caused by a foreign object, don't assume you need a foreign-body removal (FBR), laceration, or exploration code, because sometimes the absent documentation says more than what's written. Solve this case study and see if you can navigate around these pitfalls. Physician's documentation: Presenting complaint: Nail in hand.  History of present illness: Otherwise healthy left-handed roofer shot himself in the right hand with a nail gun at work three hours ago. Nail is still in place at the base of the middle finger in the palm. Last tetanus shot three years ago. No allergies. Having severe pain. Physical examination: Vital signs reviewed. Patient is in distress due to pain. Exam otherwise limited to right hand. There is a puncture wound with a nail protruding from the palm at the base of the middle finger. Limited range of motion of that finger due to the nail and pain. Sensation intact. No significant bleeding. Capillary refill brisk. No other injuries or lacerations to the hand. ED course of treatment: Doctor began IV and gave patient 1 gram Ancef. Median nerve block given at the wrist with good results. X-ray shows nail embedded in the head of the metacarpal bone. Discussion with hand doctor. He says to just remove the nail. Patient given 10 mg morphine IV in addition to block. Area prepped with betadine. Nail removed with pliers. Wound cleaned and dressed. Disposition: Home on Keflex and Vicodin. Follow-up with hand doctor later this week. Diagnosis: Foreign body (nail) embedded in third metacarpal, right hand. How should you report this treatment and diagnosis?

Keep at Level 3 for Lack of Review Despite the fact that the emergency department physician performed an important procedure on this patient, you don't have a code at your disposal that describes exactly what he did.

Ultimately, you should report only the nerve block (64450, Injection, anesthetic agent; other peripheral nerve or branch) and the appropriate evaluation and management code. In this case, that code is 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity), to which you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Cheryl Klarkowski, RHIT, coding specialist at Baycare Health System.

Based on the following breakdown, you can correctly report 99283. The patient's context  is "at work." You can consider "three hours ago" for duration. The injury's location  is on the patient's "right hand."

Modifying factors might be: The nail is still [...]