ED Coding and Reimbursement Alert

Question: How would you code the following patient presentation?

Chief Complaint: Sore throat, possible mass

History

HPI: This is a 19 year-old male with a sore throat of a week’s duration. He has pain when swallowing, no difficulty breathing but a very hoarse voice and appears uncomfortable. He has had no fever and denies any long-term medical problems but note he has been unable to tolerate liquids for 24 hours due to his inability to swallow. On closer examination he is mildly drooling. He is up to date on his immunizations. He does not currently have a primary care doctor. He complains of a sensation of lumps in his anterior neck. The pain in his throat is worse on the left than on the right and indicates it as the posterior deep neck area. He has experienced no tooth pain recently.

Review of Systems: Other than the sore throat, a 10 system review of systems was completely negative as stated above in the HPI.

Social History: No drugs, no smoking

Family History: No bleeding disorder

Past Medical History: negative

Physical Examination

Vital signs reviewed, Afebrile, uncomfortable male. Cooperative, appropriate, without respiratory distress but actively drooling

HEENT: Head is normocephalic and atraumatic. Oropharynx mass-like lesion on the left posterior oropharynx displacing the uvula to the right; however, the airway is patent. The patient has mild drooling. The floor of the mouth is benign. TMs negative bilaterally. Neck supple. No JVD. No lymphadenopathy.

Lungs: clear to auscultation bilaterally.

Heart: Regular. No gallops, rubs, or murmurs.

Abdomen: soft, non-distended, non-tender.

Extremities: limbs are warm and at raumatic with 5/5 strength

Lymph: There is anterior cervical lymphadenopathy present bilaterally; worse on the left than the right.

Psych: Normal mood and affect

Generally, no CVA tenderness.

ED Course: Patient seen and examined by myself. CBC, elevated white count.CMP unremarkable. Given Unasn  IV. Given Decadron IV. Also given Zofran and Dilaudid for pain. CT scan shows a larger peritonsillar abscess on the left. No other acute findings are seen. 

Procedure Note: Drainage of peritonsillar abscess. Patient is placed supine on the bed. Oropharynx anesthetized topically with benzocaine spray.Once adequate anesthesia was achieved the patient was positioned for an intraoral approach to drainage of this large peritonsillar abscess. With suction employed liberally due to secretions an 18 gauge needle with the cap cut was introduced into the area of maximal fluctuance. Copious puss began to drain. Dissection was then employed using a small caliber tipped suction tool with a #15 blade used to extend the incision under direct visualization. Patient tolerated the procedure well and is discharged home on Augmentin.  Patient was instructed to follow up with the ENT on call hopefully making an appointment on Monday. Patient is discharged home in good condition. Social work helped him get his Augmentin prescription filled 

Provisional diagnosis: Peritonsillar abscess on the left status post drainage, acute.

Oklahoma Subscriber

Answer: The chart has a comprehensive history and physical exam documented, and the medical decision making is high complexity level need for a level five service, consistent with a 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity). 

For the procedure you must determine if the procedure reached the level of 42700 (Incision and drainage abscess; peritonsillar) or was it actually 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst)

You’ll want to get this right because there is about a 45 percent increase in the pay if the higher code is justified by the chart documentation.  

$$$ factor: For 2015, code 10160 is assigned 2.72 total RVUs and pays $97.44 while code 42700 is assigned 3.96 RVUs and pays $141.86.

On the claim report:

• 99285-25 
• 42700 

For the diagnosis code, append:

• ICD-9 code 475 (Peritonsillar abscess) to both 99285 and 42700
• Or for ICD-10 use J36 (Peritonsillar abscess)