ED Coding and Reimbursement Alert

Question: I have a coding question on a procedure that I would like to pose to you, please. An external audit advised this should be coded as 10060. It was originally billed as 26010.  

Here is the procedure note from the chart documentation:

“Musculoskeletal/extremity: Extremities: grossly normal except: noted in the palmar aspect of distal phalanx of left thumb: decreased ROM, pain, tenderness, mild swelling, There is no evidence of ecchymosis, warmth, joint tenderness, ROM: pain with active range of motion left thumb. No pain with passive range of motion left thumb. No pain with range of motion in any left fingers or left wrist, Perfusion: the extremity is normally perfused throughout, Sensation intact. Nails: left thumb nail bitten down with small tender area at tip of mid nail with whitish discoloration suspicious for paronychia.

Skin: mild erythema and swelling distal palmar left thumb without warmth suspicious for early cellulitis secondary to paronychia.

Procedures: Nerve block: (digital) of left thumb Medication: Lidocaine 1% without epinephrine Amount: 4 mls were injected, Effect: the patient has resolution of the pain, Set up for procedure. Performed by myself.  Patient tolerated well. Performed paronychia draining. after prep with betadine, paronychia drained small amount purulent material with#15 blade, dressing applied.

Data reviewed: Vital signs, nurses notes, radiologic studies, plain films, arthritic changes, no fx and as a result, I will discharge patient. Counseling: I had a detailed discussion with the patient regarding: the historical points, exam findings, and any diagnostic results supporting the discharge/admit diagnosis, radiology results, the need for outpatient follow up, a hand specialist, to return to the emergency department if symptoms worsen or persist or if there are any questions or concerns that arise at home. Medication response: The patient’s symptoms have improved.

ED course: Patient with atraumatic left thumb pain, mild swelling and small paronychia with adjacent possible cellulitis. She has pain with active range of motion. She is able to passively range when distracted. At this point we think the infection is more superficial paronychia secondary to nail biting with secondary cellulitis rather than deeper felon, joint involvement or tenosynovitis. Drained small amount purulent material from paronychia with #15 blade, dressing applied, placed in thumb spica velcro splint. Patient needs to see ortho Monday and return to ER sooner if any worsening or persistence of symptoms which were discussed at length with patient who verbalized understanding. Multiple diagnoses were considered in the care of this patient.

Disposition: Discharged to Home Self Care. Impression: Paronychia of Finger, Cellulitis of Finger.”

Answer: First, let’s look at the best code to report the procedure. Based on the documentation, assign code 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) for the procedure with an ED E/M, probably level 2.  Use this code rather than the 26010 (Drainage of finger abscess, simple) because of the 10060 descriptor parenthetical noting drainage of a paronychia.

Secondly, we need to consider if the documentation supports a separately identifiable E/M service. The straightforward drainage of a paronychia would be coded out with 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single).  

If 10060 was reported and no prescription was given, then an ED E/M code, probably 99282-25 could be appropriate assuming the documentation requirements were met. With regard to the addition of an E/M code, most coders would feel comfortable submitting an E/M code if the documentation mentioned additional exam components, or screening for advancing or systemic infection. 

• In addition, do not apply the -54 modifier to either 10060 or 10061 since there is usually minimal follow up required. If the patient does return within 10 days for a related complaint or minor complication and he is a Medicare patient, a second E/M would not be appropriate as it would fall within the 10 day global fee period.