ED Coding and Reimbursement Alert

Question: We had this chart recently that mostly seems to be about sewing up the lacerations. Can we legitimately report an E/M service as well?

A 27 year old male was brought in by ambulance after he fell from his wheelchair in the driveway of the adjacent rehabilitation hospital. He was thrown several feet from the motorized chair when one of the wheels hit an obstruction on a slope, landing on his face on a pebbled sidewalk.  He was on the ground about 10 minutes until EMS arrived to move him after neck and spine precautions were in place for transfer. He sustained significant trauma to the right side of his face and scrapes on both his knees and left arm.

A comprehensive History and Physical Exam shows that he is in rehabilitation trying to recover the use of his limbs following prolonged critical care myopathy from months of recovering from septic shock and multiple organ system failure and is currently a dialysis patient. No tobacco or alcohol use since hospitalization seven months ago. Neurological status was checked, and he was alert and oriented X 3. CT of the skull and face were ordered along with a spinal series and labs. Physical exam shows a 4 cm diameter scrape over the right cheekbone, a 2 cm laceration on the chin, a 2 cm laceration under the nose, and a laceration low on the right cheek that has jagged edges with damaged skin flaps. 

Pupils equal round and reactive to light. Lungs were clear and heart rate was slightly elevated as was his BP. Abdomen was distended from ascetics and he complained of feeling gassy. Extremities were normal except for the abrasions noted above.

Hydrocodone and morphine were given for pain. All wounds were washed with sterile saline. Single layer repairs were used to close the lacerations under the nose and chin but the lower cheek wound required trimming the damaged skin flaps and extensive undermining, stretching the new edges to close the gap, and multi-layer closure.  Upper cheek wound was extensively cleaned, dressed and a sterile bandage was applied. Similar treatment was provided for the arm and knee abrasions. Radiology interpretations of all studies showed no broken facial bones or spinal injuries. 

The patient was discharged back to the rehabilitation hospital for follow up care with instruction to have the sutures removed in 7 days.

Texas Subscriber

Answer: Although the various laceration repairs were time consuming and the most visible treatment, there was also a separately identifiable E/M service related to assessment from the fall and comorbidities upon presentation.  The chance of skull or spinal damage was strong enough to require diagnostic studies to rule out additional injuries. This is a fragile patient medically, so a work up beyond the obvious facial wounds was warranted.

The repairs were all on the face so you should add the lengths of those of the same classification together to report as one code. Although there is mention of cleaning the wounds, it is not suggestive that all the wounds were “heavily contaminated requiting extensive cleaning” that might allow consideration as intermediate repairs. So add the repairs of the chin and upper lip together to report as one code based on the combined lengths.

The cheek repair required more debridement and revision of the wound to approximate clean edges for a repair that would not scar making it a complex repair.The radiologist provided the interpretation of the diagnostic studies so they would not be separately reportable.