ED Coding and Reimbursement Alert

From gunshot wounds to fractures, find out how to code these traumas.

Some EDs are known for their trauma centers, while others only see traumatic injuries once in a while — but no matter which category your emergency department falls into, you’ve got to be careful when coding these services. Just because your care involves a high degree of urgency doesn’t mean your codes should be assigned without some thoughtful hesitation.

Check out these three scenarios and determine how you’d code these situations before reading our advice.

1. Scan CPT^® Before Assigning Chest Exploration Code

Scenario: Your ED physician treats a patient who arrived with a gunshot wound to the chest area. The wound does not affect vital organs and the patient is alert and answering questions about the injury. The doctor debrides the wound to get to the bullet, which he extracts. He then cleans the wound area and closes the wound. The ED reports a wound exploration code and a foreign body removal (FBR) code, but the second line item (the FBR code) is denied. What went wrong?

Solution: Although the exact code would depend on the specific documentation, chances are strong that you should not report a foreign body removal code in this scenario since it’s included in the penetrating wound exploration series. Therefore, 20101 (Exploration of penetrating wound (separate procedure); chest) is likely to be the only code necessary for reporting this service.

CPT Assistant^® noted in its Vol. 16, Issue 9 edition, “Codes 20100-20103 relate to wound(s) resulting from penetrating trauma. These codes specifically describe removal of foreign body(s), as well as surgical exploration and enlargement of the wound; extension of dissection (to determine penetration); and debridement, ligation, or coagulation of minor subcutaneous and/or muscular blood vessel(s) of the subcutaneous tissue, muscle fascia, and/or muscle, not requiring thoracotomy or laparotomy. Therefore, it would not be appropriate to report an additional code for foreign body removal.”

Closing the wound is included in the wound exploration codes. However, if there is not a formal wound exploration involving enlargement to explore the wound, and the ED physician uses single-layer closure to repair a heavily contaminated wound that requires extensive cleaning or removal of particulate matter, you may be justified in reporting repair codes from the Integumentary section of CPT®.

This caveat allows you to report intermediate codes for well-documented single-layer repairs that are heavily contaminated, but your documentation must include descriptive details about the procedure such as “prior to closure, the wound required the physician to perform extensive cleaning and removal of particulate matter of the site.”

2. Consider Partial vs. Complete X-Rays

Scenario: A patient presents to the urgent care center with head trauma and the physician suspects a broken jaw. The documentation indicates that X-rays of the mandible were taken. How should you report the imaging?

Solution: It’s hard to say which code applies to this situation without the documentation of how many X-rays of the mandible were performed. The codes are as follows, and specifically note the number of views required:

• 70100 (Radiologic examination, mandible; partial, less than 4 views)
• 70110 (…complete, minimum of 4 views)

Partial vs. complete: Less than four views on X-rays implies a partial radiological assessment whereas four or more views implies a complete assessment. If your urgent care physician suspects an isolated mandibular fracture, the typical X-ray views will include the posteroanterior (PA) view, a Towne view (anteroposterior [AP] axial view), and bilateral oblique views. However, your physician may include some more views to obtain better definition of the fracture. Some examples of these specific views include the Waters (occipitomental view), periapical, or basal (submentovertex view).

As an aside, remember to use the appropriate “external cause” ICD-10 code in addition to the mandible injury diagnosis code when submitting the claim. For instance, if the patient has a right condylar mandible fracture caused by a fall off a scooter, you’d report S02.611A (Fracture of condylar process of right mandible, initial encounter for closed fracture) and V00.141A (Fall from scooter (nonmotorized), initial encounter).

3. Evaluate Options for Neurological Exam Following Injury

Scenario: A 72-year-old patient slips in her bathtub and presents to the ED with a small laceration on her forehead. In addition to suturing the wound, the ED physician performs a neurological examination to ensure that the patient doesn’t have any internal injuries to her head. Can the exam be coded separately?

Solution: Yes, you can include the neurological assessment as part of your E/M service for the day. You should report the appropriate-level ED visit code (99281-99285, Emergency department visit for the evaluation and management of a patient ...) appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) if the exam is a significant, separately identifiable service from the repair. All repair codes include a minor related history, examination of the specific localized area, and medical decision making. A neurological examination, however, represents a separate service from the laceration’s minor E/M.

In this situation, report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less), as well as the appropriate ED E/M code appended with modifier 25. As with the scenario in question two above, you’ll want to include a separate diagnosis code to indicate the cause of the injury. So, in addition to billing the ICD-10 code S01.80XA (Unspecified open wound of other part of head, initial encounter), you’ll also report W18.2XXA (Fall in (into) shower or empty bathtub, initial encounter).