ED Coding and Reimbursement Alert

Question: A patient presents to the emergency department after he cut the tip of his finger off while removing the grass catching attachment from his lawnmower. In addition to the E/M documentation, the chart notes read as follows: “13:51 Hemostasis: Moderate amount of left phalanx of 3rd and 4th digits. Controlled using cauterization of both digital arteries of 4th digit, gel foam. Bleeding stopped.” Can I report code 20103 for this service?

Alabama Subscriber 

Answer: Code 20103 (Exploration of penetrating wound [separate procedure]; extremity) is located in the Wound Exploration – trauma (e.g., penetrating gunshot, stab wound) section of CPT^®. The injury caused by a lawn mower blade does not accurately describe a wound exploration of penetrating trauma. Since there is no actual mention of closure in the chart note provided, you would have to default to an E/M code to report your work.

Not all traumatic amputations are that straightforward, some do require repair.

Typically, this kind of ED presentation of a partially amputated finger includes stabilizing the injury, extensive undermining and debridement before suturing the remaining skin over the exposed bone. This scenario would commonly be reported using a complex laceration repair code such as 13131 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm).

In cases where the exposed bone is too long for such a repair, a rongeur is often used to snip the bone back far enough to leave a suitable skin flap before the repair is performed. Depending on the documentation, you might consider reporting that extra work with code 11044 (Debridement, bone [includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed]; first 20 sq cm or less). Be advised that there are CCI edits between 11044 and the laceration repair codes.

Take note:  The CPT^® book adds language to support the changes to the debridement code section revision.  It states that complex repair includes the repair of wounds requiring more than layered closure, viz., scar revision, 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.  Debridement is separately reported only if it is extensive or requires prolonged cleaning.

So, depending on the nature of the bone debridement, only the complex repair code should be reported along with an appropriate E/M code, probably a level four or five service depending on the chart documentation. There is also a code for partial finger amputation, 26951 (Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure), but depending on the documentation that is less likely the service being provided in the ED.

For the scenario in the question, if there was a well-documented closure involving extensive debridement, and undermining, along with a layered closure 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)

• Append modifier 25 to 99284

• 13131 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm)

• 886.0 (Traumatic amputation of other finger[s] [complete] [partial]; without mention of complication) to 99284 and 13131

• Or ICD-10 S68.119A (Complete traumatic metacarpophalangeal amputation of unspecified finger, initial encounter)

• E920.0 (Accidents caused by cutting and piercing instruments or objects; powered lawn mower) to 99284 and 13131

• Or ICD-10 W28.XXXA (Contact with powered lawn mower, initial encounter)