ED Coding and Reimbursement Alert

Question:
Chief Complaint: Shoulder pain, Injury to left shoulder
History of Present Illness: Patient is a 15 year-old male who presents to the ED for evaluation after an injury to the left shoulder just PTA. He was wrestling with a friend and he was slammed to the floor. States he felt a "pop" in his left shoulder. States he did hit his head but no LOC. Pain rated as 8/10. There are no other complaints at this time.
ROS: Constitutional: Negative. Cardiovascular: Negative. Musculoskeletal: Left shoulder pain.
ROS: All systems are reviewed and are negative except as noted in the HPI and ROS.
Allergies: Review of patient's allergies indicates no known allergies.
Past Medical History: No past medical history.
Family History: His family history is not on file.
Social History: Patient has no smoking history. Patient denies alcohol use, drug use.

Physical Exam
Vital Signs reviewed and are normal.

General/Constitutional: Well-developed, well-nourished individual in moderate pain.
Neurologic: Alert and oriented. Pupils are equal, round, and reactive. No focal neurological defects are observed.
Head: Small contusion on left forehead.
ENT: Some slight blood in the nares from bloody nose, otherwise normal.
Neck: Supple.
Respiratory: Respiratory and chest exam normal
Cardiovascular: Cardiovascular exam normal.
Back: Normal back exam, no tenderness noted.
Musculoskeletal: Obvious deformity of left shoulder. 2+ radial pulses bilaterally.
Skin: Normal
Psych: Psychiatric exam included findings of patient oriented to person place and time, normal affect.
GI: Negative

Orders:
Cardiac monitoring, Done, Time: 10:00 1/1/17
IV Saline lock, Done, Time: 10:00, 1/1/17
Ortho-Sling, Done Time: 11:09, 1/1/17
Oxygen-Nasal cannula 2 LPM, Done, Time: 10:04 1/1/17
CT Head, w/out contrast, Done, Time: 12:00, 1/1/17
X-ray Shoulder, 1V, Done, Time: 11:19, 1/1/17
X-ray Shoulder, 3V, Done, Time: 10:13, 1/1/17

Medication Administration Summary

Propofol, 200 mg, IV, Given, Time: 10:25 1/1/17
Fentanyl, 50 mcg, IV, Given, Time: 10:10, 1/1/17
Keterolac injection, 30mg, Given, Time: 09:45, 1/1/17

Joint Reduction, ED physician (Dr. A): 15 year-old male presents with left shoulder dislocation. No fracture on initial x-ray. I initially attempted to relocate shoulder with manipulation and shoulder injection. Patient was unable to tolerate this, therefore he received Propofol and after moderate sedation the shoulder was easily reduced. Post procedure assessment: capillary refill less than 2 seconds, distal sensation intact, no signs of compartment syndrome. Patient tolerated the procedure well. Post procedure x-ray-normal. Final impression: Left shoulder dislocation, status post reduction. Patient was discharged home to f/u with orthopedics in office.

Moderate Sedation Note, ED physician: Procedure verified. Pre-procedure assessment: Dentition not prohibitive. Neck range of motion normal. There are no complicating factors. Patient is normal and healthy. Procedural sedation performed by ED physician Dr. B, in support of procedure performed by Dr. A. Physician at beside; procedure started at 10:57. Sedation Start time: 10:45, 1/1/17. Fentanyl given IV, amount given 50 mcg. No swelling during administration. Propofol given IV. Physician B left the room after completion of the procedure at 11:06. Total sedation time: 21 minutes. After procedure, vital signs returned to baseline, lungs clear, O2 sat 100%. Patient alert and conversing. Patient tolerated the procedure well.

Head CT: Normal

Answer: This patient presents with an obvious shoulder deformity, in significant pain, along with a head blow and a bloody nose. The documentation of history and physical exam support a level five ED E/M and the medical decision making scores as high complexity with the various high risk medications, CT scan, and concern for the possible head injury in addition to the shoulder dislocation.

In addition to the shoulder reduction, a partner was called over to provide the moderate sedation rather than the treating physician providing the sedation in support of his own procedure. There is documentarian of over 10 minutes of intraservice time, actually 21 minutes, which qualifies for reporting the moderate sedation code. In fact the record includes a very nice moderate procedure note that provides the start and stop times of the intraservice as well as the total intraservice time.

On your claim report

For physician A:

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 physical exam and medical decision making of high complexity...)

Add Modifier 57 (Decision for surgery), to show the E/M involved a decision for surgery on a 90 day global code

23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia)

For physician B:

This sedation involved a second provider, the patient was greater than age five and the intraservice time was 21 minutes. According to the table provided in CPT^® you would report:

99156 (Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; first 15 minutes of intraservice time, patient age 5 years or older).