ED Coding and Reimbursement Alert

See if you can handle the coding when a patient handles fire

 A simple accident can sometimes cause multiple complex tasks for physicians in the ED - and that difficulty transfers to the chart. Solve this case study to master multiple laceration repairs and debridement codes.

Presenting complaint: Firecracker blew up in hand
 
History of present illness: A 17-year-old male who was trying to light his own firecracker, which he made with a pipe and gunpowder, had it go off in his hand about 30 minutes before arrival in the emergency department (ED), leading to injuries to that hand. He is right-handed and otherwise healthy. Up-to-date on tetanus. He also complains of pain in his right eye and thinks he may have gotten something in it. Ears are ringing. No chest or abdominal symptoms.
 
Physical exam: Alert, in pain VS reviewed
 Scalp atraumatic
 TM's intact
 Eyes: Right is red and injected. Does appear to be some particulate debris in it.
 PERRL EOMI fundi (-)
 Chest clear
 Heart RRR
 Abdomen nontender
 Extremities (-), save for right hand. There is loss of soft tissue from the tips of his index and long fingers with a little bit of exposed bone. Some first-degree burn of the adjacent tissue as well. Proximal N-V and tendon exam (-)
 
ED course of treatment:
 
Eye: Topical anesthetic placed in right eye. Multiple tiny pieces of superficial debris removed from conjunctival sac. Two foreign bodies lodged in the cornea. Fluorescein stain shows uptake only in the areas of the foreign bodies. Using slit lamp, both of these were removed with the point of a needle. Eye rinsed again and antibiotic drops instilled.
 
Hand: Digital blocks to both fingers with Marcaine. X-rays show soft tissue loss at the tips, no fractures. Hand prepped with betadine and sterilely draped. Tourniquet control employed. The exposed bone from each finger was trimmed with a bone rongeur. There was enough tissue left to debride the edges and free it up so that adequate coverage could be obtained. This was done on both fingers. Skin over tips closed with 5-0 black nylon with resulted laceration line being 1.5 cm on each finger. Tourniquet released. Dressings applied.
 
Disposition: Discussed with Dr. Hand. He will recheck in three days. Prescriptions of cephalexin and Vicodin. See Dr. Eye if eye is not better in the morning.
 How should you report this scenario?

Find PMH for a Level Four

 For the evaluation and management code in this case, you should report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history, a detailed examination, and medical decision making of moderate complexity), says Sharon Clement, CPC, business manager for the ED physician group at the Norwalk Hospital Emergency Department in Norwalk, Conn. You may have difficulty outlining the patient's past medical history (PMH), but you have enough information to use it appropriately.
 
A level-four emergency department E/M requires a detailed history composed of an extended history of present illness (HPI) (at least four elements), an extended review of systems (ROS) (at least two elements), and at least one element out of three from the patient's past/family/social history (PFSH). At first glance, there is no specifically documented ROS or PFSH for this patient. However, you may draw these elements from anywhere they appear in the chart, which means you can satisfy these requirements all from the HPI section. Look at the bold print to see how:

History of present illness: A 17-year-old male who was trying to light his own firecracker, which he made with a pipe and gunpowder, had it go off in his right hand [LOCATION] about 30 minutes [DURATION] before arrival in the emergency department, leading to injuries to that hand. He is right-handed and otherwise healthy [CONTEXT: hurt when firecracker went off]. Up-to-date on tetanus [PAST MEDICAL]. He also complains of pain in his right eye and thinks he may have gotten something in it [ASSOCIATED SIGNS AND SYMPTOMS]. Ears are ringing. No chest or abdominal symptoms [ROS: ENT, cardiovascular or respiratory, and GI].

Scan the Bill to Handle Foreign-Body Removal

You can describe the physician's removal of foreign bodies from the eye with codes 65205 (Removal of foreign body, external eye; conjunctival superficial) and 65222 (... corneal, with slit lamp).
 
A superficial foreign body to the eye would be one that the physician can easily remove from the surface by irrigation, swabbing, or the edge of a needle, says Tracie Christian, BS, CPC, CCS-P, director of coding, technical, and training services at ProCode/The Schumacher Group in Dallas. An embedded foreign body, however, is one that has probably been pushed beneath the eye's surface and may require the physician to perform an incision to remove it.
 
"In this case, it is specified that superficial corneal bodies were removed (65205), plus additional corneal foreign bodies were removed using a slit lamp (65222)," Christian says.
 
Keep in mind, however, that often, when a scenario ends up as complex as this, the charges begin to mount, and some practices choose not to charge for all services. Check with your practice's protocol about whether you should keep the foreign-body removal charges on the tab.

No Muscle in Finger Code

 As for the finger repair, your best bet is to use code 13132 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm), Clement says. The digital blocks are included in the procedure code, so don't report them separately.
 
Even though each finger's repair was only 1.5 cm, 13132 is still appropriate. When the physician repairs lacerations that are from the same anatomic area and are of the same complexity, you combine those lengths and assign the CPT code that reflects the total length of wound repair, Christian says. In this case, you add together two complex finger repairs of 1.5 cm each, which equals 3 cm.