ED Coding and Reimbursement Alert

Question: Review this case of a presentation for a finger injury and check your code assignment against our experts.

Chief Complaint

Finger pain, traumatic

History of Present Illness

A 33 y.o. male presents for right third finger pain. Pain is moderate to severe.  Pt states it began 1 week ago and felt a piece of metal was stuck in finger. Pt states it is swollen, redness, streak to hand and cannot bend finger. Pt feels he has a FB to finger and is infection, td 4 year ago.  Pt states no fever, no chills, no other trauma.

Review of Systems:

See HPI, all other systems reviewed and are otherwise negative
Constitutional: No fever
Eyes: No eye drainage
HENT: No runny nose
Cardiovascular: No chest pain
Respiratory: No shortness of breath
Gastrointestinal: No vomiting or diarrhea
Genitourinary: No dysuria
Musculoskeletal:  No leg swelling
Skin: No rashes
Allergic/Immunologic: No hives
Neurological: No slurred speech

Allergies: Review of patient’s allergies indicates no known allergies.

PFSH:

Past Medical History: He has no past medical history on file. No history of diabetes. No history of cellulitis.
Past Surgical History: He has no past surgical history on file.
Medications: Not on File
Family History: His family history is not on file.

Social History: He reports that he has never smoked. He does not have any smokeless tobacco history on file. He reports that he does not drink alcohol. His drug history is not on file.

Physical Exam

Reviewed vital signs and nursing note as charted by RN. 
CONSTITUTIONAL: Alert and oriented and responds appropriately to questions. Well-appearing; well-nourished
HEAD: Normocephalic; atraumatic
EYES: PERRL; Conjunctivae clear, sclerae non-icteric
BACK:  The back appears normal and is non-tender to palpation,
EXT: Normal ROM in all joints; non-tender to palpation; no cyanosis, no effusions, no edema   rt.  middle finger, tensely swollen, small  fb?  or punctate area to ulnar volar aspect. No flexion of MCP/PI/DIP due to pain, streak noted dorsally to hand. No tenderness over olecranon nodes, plus 2 cap refill.  Fluctuance with punctate area, probable puss under skin
SKIN: Normal color for age and race; warm; dry; good turgor; no acute lesions noted
NEURO: Moves all extremities equally; Motor and sensory function intact 
PSYCH: The patient’s mood and manner are appropriate. Grooming and personal hygiene are appropriate.
ABD/GI: Normal bowel sounds; non-distended; soft, non-tender, no rebound, no guarding; no palpable organomegaly or masses.
CARD: RRR

Orders:

Labs: Blood cultures, sed rate, Westergren, BMP, CBC with differential

X-ray right finger
Insert peripheral line IV
Zofran 4mg injection
Morphine 4 mg/ml (four doses) IV
Dilaudid 1mg IV

Results

X-ray Finger Right

Final Result

Exam: Right Third Finger
History:  Penetrating injury to third finger.
Technique:  3 views
Comparison: None
Findings:  3 views of the right middle finger, third finger, or performed. There is no fracture, malalignment or bony destructive lesion. Joint spaces are normal. There is no radiopaque foreign body.
Impression: negative right middle finger. Interpreted by the ED physician
Labs: CBC with platelet and differential: Abnormal result WBC 12.2

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Answer: This is a good example of a seemingly simple or moderate problem presentation turning out to be a serious, level 5 problem. A serious infection to a finger can turn serious quickly and the risk of morbidity without treatment is high with a high probability of severe, prolonged functional impairment. The history and physical exam documented are comprehensive and the medical decision making is of high complexity, justifying a 99285 code assignment.

You would report these codes on the claim:

• 99285-25 (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…)
• 26011 (Drainage of finger abscess; complicated [e.g., felon]),
• 73140-26 (Radiologic examination, finger[s], minimum of 2 views)

Assign ICD-10 codes

M65.841 (Other synovitis and tenosynovitis, right hand)
M65.331 (Abscess trigger finger right middle finger)
L03.011 (Cellulitis of finger of right finger)
I89.1 (Lymphangitis)