ED Coding and Reimbursement Alert

Question: How would you report the following service?

A 28- year-old male presents to a freestanding ED at midnight after being struck on the head from a lava lamp that fell off his headboard bookshelf.  He reports the injury occurred about 45 minutes prior with excessive bleeding that was controlled after pressure was applied with a clean damp cloth for some time. He had recently finished a dialysis treatment and had a heparin injection about four hours prior to the accident. He reports no loss of consciousness resulting from the injury, no blurred vision or dizziness, but does state that he had taken a sleeping pill just prior to the injury. Patient is in renal failure necessitating dialysis treatments four times a week and has limited use of his right arm and legs from neurological impairment following a prior prolonged illness. Patient reports his tetanus immunization is up to date.

The gauze bandage placed at home that covered the wound was removed, exposing a 2.25 cm laceration just above the left eyebrow. The wound was carefully irrigated and examined. There was no active bleeding.  Patient is alert and oriented with pupils round, reactive, and accommodating. After consultation with the patient, the discussion was to close the wound using adhesive rather than sutures. The site was prepared, the edges approximated, and secured with Dermabond adhesive.  Because of the extensive list of the patient’s current medications, I discussed the need for caution in prescribing pain medication. A prescription for ten Hydrocodone 7.5 mg tablets was given. After observing the patient for any ill effects and letting the adhesive set, he was discharged with detailed wound care instructions and told to follow up as needed.

Answer: Although the wound was not complicated, this patient had a complex history because of his many current medications and being in renal failure. What would otherwise have been a problem focused exam becomes more complex due to his chronic medical conditions impacting treatment, as well as the prescription for pain medication. CPT® instructs that a simple repair using adhesives should be reported the same as if sutures were used for the closure.

On the claim report:

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history, an expanded problem focused examination; and medical decision making of moderate complexity)

• 12011(Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less)

Payment note: Because this was a privately owned, independent freestanding ED, a facility charge would also be reported, probably a level 2 (AAPC 613 or HCPCS G08381) based on the prep and treatment of a simple trauma with no x-rays.