ED Coding and Reimbursement Alert

Question: I am having trouble with the chart below. What codes should I use to report the treatment of the injuries sustained?

CHIEF COMPLAINT: Dictated. 20 year old male presents with an injury. He fell off of a dirt bike, motorized 1 hour ago. He struck his right knee against a railroad track or tie. He states it is very painful with a constant 9/10 pain. He has not been able to ambulate on it. It hurts more when he moves it or touches it. He suffered an open laceration. He states his last tetanus shot was approximately five years ago. He denies any other significant injuries or pain from the fall.

PAST MEDICAL HISTORY

MEDICAL HISTORY: No significant past medical history.
SURGICAL HISTORY: Patient has had no previous surgical history.
PSYCHIATRIC HISTORY: No previous psychiatric history.
SOCIAL HISTORY: Denies tobacco abuse, drug abuse. Patient consumes alcohol daily. (20:49 NJGP)
NOTES: Nursing records reviewed.

ROS

CONSTITUTIONAL: No fever, chills.
EYES: No eye redness.
ENT: No epistaxis.
CARIOVASCULAR: No chest pain, syncope.
RESPIRATORY: No SOB.
GI: No abdominal pain, vomiting.
GENITO URINARY FEMALE: No dysuria.
MUSCULOSKELETAL: Historian reports fall, injury, joint swelling. No neck pain, back pain
SKIN: Historian reports skin lesions.
NEUROLOGIC: No dizziness, paresthesias, focal weakness.
HEM OIL YMPHA TIC: No easy bleeding.

PHYSICAL EXAM

CONSTITUTIONAL: Vital signs reviewed. Patient appears uncomfortable
HEAD: Atraumatic, Normocephalic.
EYES: Eyes are normal to inspection. No discharge from eyes.
Ears: No discharge or hemotypmpanum
NECK: No meningeal signs, Cervical spine nontender
RESPIRATORY CHEST: Chest is nontender. No respiratory distress
CARDIOVASCULAR: RRR. No murmurs.
ABDOMEN: Abdomen is nontender. No distension.
LOWER EXTREMITY: Left knee range of motion is limited, details dictated.

Left knee shows, just proximal to the left knee, there is a very long, extensive laceration. It measures 15 cm in length. It is across the entire portion of the knee in curvilinear. Physically it appears to be above the knee joint but in subsequent exploration it probably is at the top edge of the knee joint and the top edge of the patella on the lateral aspect is involved. On examination he has significant discomfort with straight leg raise, although he is able to keep his knee in full extension and raise his foot off the table. Direct visualization of the wound reveals a laceration of the lateral insertion of the quadriceps to the patella. The wound is heavily contaminated with dirt, leaves, twigs and tar.

NEURO: No focal motor deficits, focal sensory deficits, cerebellar deficits.
SKIN: Skin is warm, Skin is dry, laceration extensive.
PSYCHIATRIC: Oriented X 3. Normal insight.
DOCTOR NOTES
TEXT: All laboratory and/or X-ray and EKG results entered on chart have been reviewed and interpreted by me, explained to patient, and used to formulate diagnosis and disposition.

Procedure Note: Initial attempts at cleansing this are unsuccessful. He was anesthetized with 1% lidocaine with Epinephrine around the entire wound perimeter. However, this did not lead to adequate analgesia for allowing for cleaning. He gave informed consent for procedural sedation. He received both pain medicines IV, including morphine and Dilaudid, Phenergan, and then was given Propofol IV at an initial dose of one mg per kilo and continued aliquots to a total of almost two mg per kilo. Sedation was achieved although he still had significant discomfort. Using the Pulsavac the wound was cleaned as best as possible with significant removal of particulate debris. Direct debridement was also carried out plus continued irrigation. At this point the patient started to wake up and the procedure had to be terminated after 21 minutes. I explained to his family, who is present that we had used the maximal dose of Propofol that I was comfortable using in the Emergency Department without taking him to the operating room. At that point the wound was stapled closed. X-rays were obtained and showed a question of a bony injury with the lipohemathrosis. There was no obvious free air seen in the joint on plain x-rays so a CT scan was obtained. Clinically, I felt after the opportunity to explore the wound better under procedural sedation that it likely had penetrated into the joint space and I had contacted a surgeon about the same. He felt that without free air, this would not be as likely, therefore CT scan was done. CT scan did show free air in the joint, consistent with penetration. The surgeon will be seeing the patient early in the morning, with the probability of taking him to the OR for further cleaning and washing out of the joint, as well as removing the remaining foreign debris that I was unable to get out in the Emergency Department.

The wound was stapled closed with 24 staples temporarily to achieve hemostasis until could perform more definitive care. Patient received further pain medication, was actually quite comfortable after the wound was closed. He tolerated the procedural sedation well, maintaining verbalization throughout even though he did not recall a lot of the procedure and maintaining a normal pulse oximetry.

ASSESSMENT:

1. Significant wound to the leg with contamination.
2. Quadriceps laceration.
3. Possible fracture of the edge of the patella.
4. Probable contamination of the knee joint space.

PLAN: As above.
DIAGNOSIS FINAL: PRIMARY: laceration, ADDITIONAL: quadriceps laceration.

Answer: This is an interesting case in that it has both a complicated repair along with a complicated sedation service. Although the wound is deep, involving the quadriceps muscle, and heavily contaminated, the actual closure only qualifies as a simple repair with the placement of staples until surgery can be performed the next day. However, because of the excessive debridement required, you could argue that the repair reached the intermediate threshold.

On the claim, report the following codes:

• 99285 (Emergency department visit 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: a comprehensive history; a comprehensive examination; and medical decision making of high complexity...) with modifier 25(Significant separately identifiable E/M service on the same day) appended.
• 12035 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 12.6 cm to 20.0 cm)
• Since an intermediate repair has a 10-day global period and the surgeon is going to open the wound to repair the joint space, you should add modifier 54 (Surgical care only) to code 12035.
• 99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time).