EM Coding Alert

A patient that has a possible skull fracture would likely receive some sort of evaluation and management (E/M) service followed or prompted by an imaging service to confirm the fracture, says Sherrie Thevel, MS, CPC, CPPM, CPC-I, CRC, manager of risk adjustment at Aetna CVS in Arnold, Missouri. This could be done for a patient in the office or in the hospital, depending on the situation.

If the surgeon performs an office/outpatient E/M as part of an evaluation for a possible skull fracture, you’d choose from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/ or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) code set, depending on whether the patient is new or established.

You’ll also see patients at the hospital for skull fracture-related E/Ms; these could (conceivably) be just about any type of hospital E/M, but typically the E/M is classified as an emergency department (ED) E/M, initial hospital care, or consultation.

If the surgeon performs an ED E/M as part of an evaluation for a possible skull fracture, choose from the 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making...) through 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...) code set, depending on encounter specifics.

If the surgeon performs a consultation, you meet the requirements for consultation, and the payer recognizes consultation codes, you’ll report a code from 99251 (Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making…) through 99255 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity...), depending on encounter specifics. Otherwise, report initial hospital care with 99221-99223.

After the E/M, the surgeon will likely order imaging studies of some sort. According to Thevel, the codes you’d most likely use for skull imaging are:

• 70250 (Radiologic examination, skull; less than 4 views)
• 70260 (… complete, minimum of 4 views)
• 70450 (Computed tomography, head or brain; without contrast material)
• 70460 (… with contrast material(s))
• 70470 (… without contrast material, followed by contrast material(s) and further sections)
• 70496 (Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing)

Example: Thevel says many skull fracture patients first report to the ED after some sort of trauma. For instance, a patient with trauma reports to the ED with a suspected skull fracture. The ED physician calls a neurosurgeon in to check the patient. The surgeon performs an E/M service with a detailed history and exam and low-level medical decision making (MDM), and then requests and reviews a complete skull X-ray that confirms a skull fracture, unless the ED physician already obtained the radiographs.

For this encounter, if your surgeon is the first to review the radiographs and has privileges to do so, you’d report 70260 for the X-ray with modifier 26 (Professional component) appended since as the surgeon you don’t own the X-ray equipment. Then, if you are not assuming care from the ED physician, you’d report 99253 (… A detailed history; A detailed examination; and Medical decision making of low complexity...) for the consult with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to show that a significant, separately identifiable E/M preceded the X-ray. If you determine that the fracture requires major surgical treatment which is performed the same or following day, then append modifier 57 (Decision for surgery) instead.

Note These Symptoms for Skull Fractures

Knowing what a skull fracture patient looks like can help with your diagnosis coding. According to Johns Hopkins Medicine, symptoms of skull fracture include, but are not limited to:

• Loss of consciousness
• Severe headache that does not go away
• Repeated nausea and vomiting
• Loss of short-term memory, such as difficulty remembering the events that led right up to and through the traumatic event
• Slurred speech
• Difficulty with walking
• Weakness in one side or area of the body
• Sweating
• Pale skin color
• Seizures or convulsions
• Behavior changes including irritability
• Blood or clear fluid draining from the ears or nose
• One pupil (dark area in the center of the eye) is dilated, or looks larger, than the other eye and doesn’t constrict, or get smaller, when exposed to light
• Deep cut or laceration in the scalp
• Open wound in the head
• Foreign object penetrating the head
• Coma (a state of unconsciousness from which a person cannot be awakened; responds only minimally, if at all, to stimuli; and exhibits no voluntary activities)
• Vegetative state (a condition of brain damage in which a person has lost their thinking abilities and awareness of surroundings, but retains some basic functions such as breathing and blood circulation)
• Locked-in syndrome (a neurological condition in which a person is conscious and can think and reason, but cannot speak or move)

Remember: If your neurosurgeon doesn’t reach a definitive diagnosis of skull fracture, you’ll code the symptoms rather than coding for a skull fracture.

Example: A patient reports with severe headache and a deep cut on the scalp, but the surgeon finds no skull fracture. For this patient, you’d choose ICD-10 codes for the headache and the skull laceration rather than a skull fracture.

If the surgeon confirms a skull fracture, then you’ll choose from the ICD-10 subcategories for skull fracture, S02.0- (Fracture of vault of skull) and S02.1- (Fracture of base of skull).

Remember These 3 Codes for Fracture Fixes

If the surgeon confirms a skull fracture and repairs it, you’ll chose from the following codes, Thevel confirms:

• 62000 (Elevation of depressed skull fracture; simple, extradural)

Analysis: A depressed skull fracture may or may not involve a cut in the scalp. “In this fracture, part of the skull is actually sunken in from the trauma. This type of skull fracture may require surgical intervention, depending on the severity, to help correct the deformity,” explains Thevel.

• 62005 (… compound or comminuted, extradural)

Analysis: A compound/comminuted fracture “involves a break in — or loss of — skin, and splintering of the bone,” according to Thevel.

• 62010 (… with repair of dura and/or debridement of brain)

Analysis: “Assessment of integrity of dura in depressed skull fracture is of paramount importance because if dura is torn, lacerated brain matter may be present in the wound, which needs proper debridement followed by watertight dural closure to prevent meningitis, cerebral abscess, and pseudomeningocele formation,” says Thevel.