ED Coding and Reimbursement Alert

Barefoot summer days are supposed to salve the soul, but they often end in ED presentations for foot injuries. Check out these case studies for clues on coding common ED foot procedures.

Patients who report to the ED with toe crush injuries might require trephination to release blood (or fluid) from beneath the nail. When the ED physician performs only trephination, report 11740 (Evacuation of subungal hematoma) for the encounter, confirms John F. Bishop, PA-C, CPC, president of Bishop & Associates Inc. in Tampa, Fla.

Example: A patient reports to the ED with a badly bruised right great toe; there is a buildup of blood and pus beneath the nail. Using a small needle, the physician bores a hole in the nail to relieve pressure and drain fluid. In this instance, report 11740 with 924.3 (Contusion of lower limb and of other and unspecified sites; toe) appended to represent the patient's injury.

"This [procedure] can be done with a scalpel, a hot paper clip, cautery, or with a needle used as a drill," explains Robert LaFleur, MD, FACEP, of Medical Management Specialists in Grand Rapids, Mich. The key factor for 11740 is that the physician drilled into the nail to release underlying blood.

Case: Cutting Nail to Access Underlying Problem

There are patients who will report to the ED requiring a nail avulsion, which is partial or total toenail removal for treatment. In these instances, you'll report 11730 (Avulsion of nail plate, partial or complete, simple; single) for the first nail and +11732 (... each additional nail plate [List separately in addition to code for primary procedure]) for any additional nails.

The ED physician may have to perform this procedure "to remove a clotted hematoma, foreign body, etc.," Bishop explains.

Example: A patient has an open toe crush injury, and the physician suspects a nail bed laceration, so she removes the nail. Upon examination, the physician decides the toe needs no further repair.

In this instance, you can report 11730 for the service with 893.0 (Open wound of toe[s]; without mention of complication) appended, confirms LaFleur.

If the ED physician removes a patient's nail as part of the treatment, and then sutures the nail bed to prevent further injury, it is a nail bed repair service. Code these procedures with 11760 (Repair of nail bed), says Karen Fulmer, CPC, coder at Robinson Memorial Hospital in Ravenna, Ohio.

Example: An 11-year-old child presents to the ED with his father after shutting his great right toe in a door; the injury ripped the nail back, and it is now dangling from the patient's nail bed. The ED physician removes the nail plate without complication, cleanses the area with Betadine, and explores the injury in a bloodless field. The physician then sutures the nail bed closed with four 5-0 simple interrupted sutures.

In this instance, you'd report 11760 with 893.0 appended.

Patients presenting to the ED with ingrown toenails often require a wedge excision, which is "removal of the inflamed tissue adjacent to the nail and a section of the nail itself, along the whole length of the nail," relays LaFleur. CPT represents this procedure with 11765 (Wedge excision of skin of nail fold [e.g., for ingrown toenail]).

Example: A patient in the ED is suffering from an ingrown left second-digit toenail. The physician wedges the nail to treat the ingrowth, then packs it with Iodoform gauze. In this instance, report 11765 with 703.0 (Ingrowing nail) appended.

When the physician performs trephination (11740) during the same session as any of the following procedures, 11740 is bundled and you cannot report it separately:

• avulsion (11730, +11732)

• nail bed repair (11760)

• wedge excision (11765).

Example: The ED physician performs avulsion on a patient's great left toenail and second digit nail. During the great toe treatment, the physician performs trephination with a cautery tool to drain blood collected under the nail.

In this instance, you would report only 11730 and +11732 for the encounter.