ED Coding and Reimbursement Alert

Question: How would you code this chart? We have some concerns about who provided/performed each of the procedures mentioned in the documentation.

Louisiana Subscriber

Patient is a 13-year-old male who presents to the emergency department with a chief complaint of an injury to his upper arm.

HPI

A 13- year-old otherwise heathy boy fell off his bicycle and injured his left forearm. He was riding his bike downhill when he hit a pothole in the road and fell off. He suffered an obvious deformity to his left forearm, but was otherwise unhurt he claims he did not hit his head, shows no other signs of injury and reportedly has been acting normal since the accident. There was no loss of consciousness. He last ate at 20:30. He has been given two Tylenol 325 mg by his mother for the pain with some relief. He rates his pain as initially 10/10 two hours ago right after the accident but now is at 6/10 after the Tylenol.

Review of Systems

Constitutional: Negative
Eyes: Negative
HEENT: Negative
Cardiovascular: Negative
Respiratory: Negative
Musculoskeletal: Negative except for injured left forearm
GI: Negative
Neurologic: Negative
Skin: Several abrasions on the left forearm

All other systems reviewed and negative 

PFSH

Patient lives with his parents, does not smoke or consume alcohol, and is not sexually active. He attends middle school.

No significant prior medical or family history. He has no know allergies and his immunization status is up to date.

Physical Exam

Constitutional: Pulse 100, Temp 97.5, Respirations 20, Weight 50 kg or 110 pounds, Oxygen saturation is 100 percent. He is oriented to place and time and appears well developed and well nourished.
Head: Normocephalic, and atraumatic.
Eyes: Conjunctiva and extraocular motions are normal. Pupils equal round and reactive to light. No discharge from either the right or left eye.
Neck: Supple with normal range of motion, no masses.
Cardiovascular: Normal rate and regular rhythm and normal heart sounds.
Pulmonary/Chest: Normal breathing, normal breath sounds, no rales no wheezing. No tenderness.
Abdomen: Normal bowel sounds; abdomen is soft, no tenderness, no distention. He has full rebound.
Musculoskeletal: There is an obvious deformity to the left forearm. Patient is neurovascularly intact. Both radial pluses are 2+ with good cap refill. There are several abrasions to the skin over the forearm and upper elbow area. There is one lesion that may communicate with the fracture, making it possibly an open fracture.
Neurological: He is awake and oriented to person, place, and time. He exhibits abnormal muscle tone.
Psych: Mildly anxious but interacting appropriately.
Heme/Lymph: No nodes or other indications of infection.

Imaging Orders

X-ray of forearm PA and lateral
X-ray of elbow 3+ Views

ED attending independent visualization and interpretation: Radius and ulna fracture with moderate displacement

Consults: Orthopedics

ED Course

X-rays show distal radius and ulnar fracture with angulation. Patient given 4mg of morphine and currently has good pain control. Patient last ate at 20:30 so will hold off on sedation until 02:30. IV Ancef given.
3:10 Patient is about to undergo sedation, reduction of left distal radius and ulnar fracture
3:30 Reduction complete, post reduction films pending

Impression and Decision Making: Left distal radius and ulnar fracture.

Discharge Plan: Discharge home after he wakes up from sedation and tolerates PO.

Signed by the Resident

Attending Note

Refer to the emergency medicine Resident Note. I reviewed the history with both the resident and the patient's mother, the historian. I personally examined the patient. I have reviewed and discussed the examination findings, and any laboratory data and/or radiographs with the resident. I agree with the assessment and the management plan. I was present during the key portion of the procedure/s noted.

Of note, there is one abrasion and one very superficial area of avulsed skin which we visualized after irrigation. No bone visible, both very superficial. IV antibiotics given empirically and orthopedics notified after initial exam of the patient. I have discussed the case with the Ortho Attending who agrees to see the patient in the ED for evaluation for possible ED sedation and reduction or if required OR washout. Signed out to Ortho Dr. Patient is comfortable and neurovascular intact.

Signed by the Pediatric Emergency Medicine Attending Physician

Answer: You have a comprehensive history with an extended HPI, 10+ element review of systems, and a complete past, family, and social history. The physical exam is also comprehensive.

Medical Decision Making: Number Diagnoses and Management Options is high with additional workup planned, Data includes review of X-rays and discussion with another provider (total 4 data points). Risk is high with multiple fractures requiring parenteral controlled narcotic pain medication.

This case involved a teaching physician and resident, and includes a consultation with orthopedics. The resident provides discussion for potential open fracture due to skin lesion over the fracture site. The chart also notes that the patient was signed out to an orthopedist by the ED attending for procedural sedation and fracture reduction. There is no flow sheet with required intraservice time documentation for sedation in the record although note indicates "sedation done." 

On the Claim Report

99285 (Emergency department for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: comprehensive history, comprehensive physical exam, and medical decision making of high complexity...)

Although the chart says that the ED attending provided an independent visualization and interpretation, noting, "Radius and ulna fracture with moderate displacement," this does not meet the standard for a separately identified interpretation and report. There is no mention at all of the elbow images ordered. So do not report either 73070 (Radiologic examination, elbow; 2 views) or 73080 (Radiologic examination of elbow, complete, minimum of 3 views) with modifier 26 (Professional component) for the interpretative report.