ED Coding and Reimbursement Alert

Question: There is no doubt about the significant injury to the toe in this scenario but what is the correct code to capture the laceration repair?

Texas Subscriber

Chief Complaint: Toe Injury

HPI: A 61 year-old female presented to the ED at 12:25 by ambulance. She was triaged at 134:28 with the following vital signs. T: 98.5, P: 86 regular, R 20 unlabored, BP: 212/97, SPO2: 95, AMT: RA, pain 7 of 10 in multiple areas. The patient's primary care physician is unknown.

Onset of symptoms was sudden and immediately prior to arrival. Pain continues and is of moderate intensity. She is negative for head trauma. States she fell over her shoes at home. Her right knee hurts and she cannot feel her left toe. She claims she hit her head but there was no loss of consciousness.

ROS: 

Constitutional: Negative chills, fever or fatigue

Cardiovasular: Negative chest pain, negative edema, negative syncope

All other systems have been reviewed and are negative

PFSH: She is positive for IDDM, but otherwise past medial history is negative. Allergies reviewed COHIST, medications reviewed; Family history reviewed but is not pertinent to this presentation.

Physical Exam:

General: well developed, well-nourished and in no apparent distress. Vital signs noted, nursing documentation reviewed.

HEENT Head and face; normocephalic/atraumatic  Eyes: Pupils equal, round and reactive to light. Extraocular motion intact. Ears; external ears, canals and TMs normal bilaterally. Nose: Normal external appearance. Septum midline and intact. Pharynx: Posterior pharynx is unremarkable.

 Neck: Appears normal with no JVD present. Neck is supple with no bony tenderness or palpable adenopathy.

 Respiratory: No respiratory distress. Lungs clear with equal breath sounds bilaterally.

Cardiovascular: PMI normal RRR. S1, S@ normal with no murmurs, clicks, gallops or runs. All distal pulses 2+ and symmetric.

Abdomen: Bowel sounds are normoactive. Abdomens is soft, non-tender, without organomegaly or palpable mass.

Back: Negative CVAT. Spine non-tender.

Musculoskeletal/ Extremity: Left big toe (1st digit) has a complex laceration present 3.5 cm in length, dislocation of IP joint.

Skin: Skin is warm and dry with normal turgor, no lesions or rash.

Neurologic: Alert and oriented to person, place and time. Cranial nerves 2-12 grossly intact. No motor or sensory deficits.

Lymphatic: No palpable lymphadenopathy

Genitourinary: Deferred

Diagnostic Test Results: 

Laboratory: (Refer to lab results report for units of concentration and reference values) The following labs have been reviewed and are normal: WBC, hemoglobin, hematocrit, platelets, PT, INR, NA K, BUN, CO2, creatinine, glucose, chloride and calcium.

ED Course and Treatment

Patient has sustained dislocation to the interphalangeal joint of the first digit of the left foot. Risks benefits and alternative discussed with patient and family and consent obtained. Anesthesia accomplished with digital nerve block. Lidocaine (xylocaine) 1% used as anesthetic agent. 

Procedure: Longitudinal traction applies to digit. Successful reduction of digit as evidenced by audible and palpable crepitus and restoration of anatomic landmarks. Neurovascular exam intact. Post reduction X-ray shows good alignment and restoration of normal anatomic relationships, no fracture

Laceration Repair: See Physical exam above for description of the wound and examination of the area/ Length of laceration is 4.5 cm on left first big toe. Wound is linear. Margins are sharp. Wound is clean. Depth of laceration involves muscle. Normal active and passive flexion/ extension. Capillary refill distal to wound normal. Distal sensory exam shows decreased sensation to light touch. 

Area prepped and wound cleansed thoroughly with Betadine. Digital nerve block employed for anesthesia. Patient anesthetized with 1% xylocaine without epinephrine. Wound irrigated with copious amounts of normal saline. Wound closed with nylon 4-0 suture material placed using simple uninterrupted technique. Number of sutures use was 7. Antibiotic ointment applied over suture line. Wound covered with sterile dressing.

Clinical Impression: 

1. Fall

2. Contusion right knee

3. Contusion left knee

4. Acute dislocation left lower extremity interphalangeal joint

5. Laceration left great toe

Disposition:  patient discharged to home, condition improved, patient's condition was emergent. Care was discussed with patient and family. Explained findings, diagnosis, and need for follow-up care.

Answer:  The E/M service is nicely documented and we have two good procedure notes documented. Procedures performed: nerve block, laceration repair, closed treatment of toe dislocation. The physician does mention a complex laceration in the physical exam, but the procedure note does not justify assigning that code. Although there is mention of the depth of the injury reaching the muscle layer, there is no mention of layered closure or interventions that justify reporting a complex repair

Keep in mind that, according to CPT®, the following is typically representative of complex laceration repair: repair of wounds requiring more than layered closure, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions.

On the claim, you would report:

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity)
• 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm)
• 28660 (Closed treatment of interphalangeal joint dislocation; without anesthesia)