Wiki Why was I marked wrong? (Practicode Case ID: OPD7259)

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Elund

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The documentation:
MEDICAL RECORD
EMERGENCY DEPARTMENT

Age 26

Sex: M

DOS: 1/1/20XX

CHIEF COMPLAINT: Left ankle pain.

HPI: This is a male who was playing football when another player landed on his left ankle and he fell to the ground. He heard a pop and saw his leg deformed. He denies any other injuries and was wearing a helmet. He otherwise feels well. He comes in with a splint on his leg, but no pain medication prior to arrival.

PAST MEDICAL HISTORY: Denies.

MEDICATIONS: Denies.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY: The patient does not smoke or drink alcohol.

REVIEW OF SYSTEMS: As per the HPI, otherwise unremarkable. He specifically also does not have any distal paresthesias, though he does have some numbness about the ankle.

PHYSICAL EXAM: VITAL SIGNS: Temperature 99.4, pulse 76, respiratory rate 16, pulse oximetry 100%, blood pressure 126/75.

GENERAL: He is a well-developed, well-nourished, pleasant young man appearing his stated age and appearing to be in a good bit of pain.

HEENT: Pupils are equal, round and reactive to light. Oropharynx, clear.

NECK: No vertebral tenderness. RESPIRATORY: Clear to auscultation bilaterally.

CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or rubs. GI: Soft, nontender, nondistended with normal bowel sounds.

EXTREMITIES: The patient's left leg is in a splint. You can see that there is notable deformity. Capillary refill distally is intact and less than 2. NEURO: Distal sensation and motion are intact.

EMERGENCY ROOM COURSE: X-ray reveals a bimalleolar fracture with a posterior and lateral malleolus fracture as well as dislocation of the ankle.

I discussed the findings with the patient and the need for conscious sedation as well as manipulation and need for ultimate surgery. Discussion occurred before pain medications were received by the patient. Risks and benefits of sedation with Diprivan were discussed. The patient agreed to proceed with sedation.

Conscious Sedation: Intraservice time - 20 minutes

I personally administered Diprivan 80 mg IV.

Respiratory Therapy was at the head of the bed and did assist with bag valve mask briefly during the procedure. The patient never was hypoxic. I manually did closed reduction and was completed of the left ankle and a 3-sided plaster splint applied. The patient tolerated this well and woke up at the end of the procedure after splinting was completed. He remains distally neurovascularly intact after splint was applied by me.

I spoke with Orthopedic physician who wishes to do surgery tomorrow. The patient does not want to stay in the hospital overnight, so is being released home. Prescription was given for Vicodin. The patient is to return at 10 a.m. Return precautions are given.

DIAGNOSIS: 1. Left ankle fracture and dislocation. 2. Status post closed reduction with procedural sedation.

DISPOSITION: Home in improved condition with plan to return for surgery in a few hours.

Clarence Kramer, MD - Electronically signed by CLARENCE KRAMER, MD 1/1/20XX


Why aren't the external cause codes reported here?

Why isn't the 80 mg propofol (Diprivan) injection reported?

And why isn't the X-ray reported? There's no mention of it being provided by anyone other than the reporting physician.
 
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Is the sedation bundled into the procedure code? Me personally, in the interest of patient safety, I would have reported the drug code so there would be a record with the payer of what the patient was given. But if it's bundled, then no, the injection wouldn't be billed separately.

Dr. Kramer would need to document that he interpreted the x-ray in order to bill the professional component. It doesn't specify that he did that--he could have just read the report.

Reporting the external cause codes wouldn't be wrong, but they're not required. And in reality, they're rarely used. I think I've only seen a handful in 10 years, and those were for things like battery, gunshots, dog bites--stuff where there may be legal action connected.
 
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elundste said:
The documentation:
MEDICAL RECORD
EMERGENCY DEPARTMENT

Age 26

Sex: M

DOS: 1/1/20XX

CHIEF COMPLAINT: Left ankle pain.

HPI: This is a male who was playing football when another player landed on his left ankle and he fell to the ground. He heard a pop and saw his leg deformed. He denies any other injuries and was wearing a helmet. He otherwise feels well. He comes in with a splint on his leg, but no pain medication prior to arrival.

PAST MEDICAL HISTORY: Denies.

MEDICATIONS: Denies.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY: The patient does not smoke or drink alcohol.

REVIEW OF SYSTEMS: As per the HPI, otherwise unremarkable. He specifically also does not have any distal paresthesias, though he does have some numbness about the ankle.

PHYSICAL EXAM: VITAL SIGNS: Temperature 99.4, pulse 76, respiratory rate 16, pulse oximetry 100%, blood pressure 126/75.

GENERAL: He is a well-developed, well-nourished, pleasant young man appearing his stated age and appearing to be in a good bit of pain.

HEENT: Pupils are equal, round and reactive to light. Oropharynx, clear.

NECK: No vertebral tenderness. RESPIRATORY: Clear to auscultation bilaterally.

CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or rubs. GI: Soft, nontender, nondistended with normal bowel sounds.

EXTREMITIES: The patient's left leg is in a splint. You can see that there is notable deformity. Capillary refill distally is intact and less than 2. NEURO: Distal sensation and motion are intact.

EMERGENCY ROOM COURSE: X-ray reveals a bimalleolar fracture with a posterior and lateral malleolus fracture as well as dislocation of the ankle.

I discussed the findings with the patient and the need for conscious sedation as well as manipulation and need for ultimate surgery. Discussion occurred before pain medications were received by the patient. Risks and benefits of sedation with Diprivan were discussed. The patient agreed to proceed with sedation.

Conscious Sedation: Intraservice time - 20 minutes

I personally administered Diprivan 80 mg IV.

Respiratory Therapy was at the head of the bed and did assist with bag valve mask briefly during the procedure. The patient never was hypoxic. I manually did closed reduction and was completed of the left ankle and a 3-sided plaster splint applied. The patient tolerated this well and woke up at the end of the procedure after splinting was completed. He remains distally neurovascularly intact after splint was applied by me.

I spoke with Orthopedic physician who wishes to do surgery tomorrow. The patient does not want to stay in the hospital overnight, so is being released home. Prescription was given for Vicodin. The patient is to return at 10 a.m. Return precautions are given.

DIAGNOSIS: 1. Left ankle fracture and dislocation. 2. Status post closed reduction with procedural sedation.

DISPOSITION: Home in improved condition with plan to return for surgery in a few hours.

Clarence Kramer, MD - Electronically signed by CLARENCE KRAMER, MD 1/1/20XX


Why aren't the external cause codes reported here?

Why isn't the 80 mg propofol (Diprivan) injection reported?

And why isn't the X-ray reported? There's no mention of it being provided by anyone other than the reporting physician.
Click to expand...


1) Reporting external cause codes isn't mandatory (see the ICD-10-CM guidelines for chapter 20). In real-life billing situations, the HCFA 1500 has limited space to report diagnosis codes, so you'll less likely see the external cause codes on the physician claim for services rendered in a facility. The facility might be more likely to report the external cause codes on the UB-04.

2) The facility would report the drug, not the ER physician. The facility purchases and supplies the drug, and the charge gets included on the facility bill.

3) The facility owns the x-ray machine, not the ER physician. The facility bills the technical component for use of their equipment. The professional component is billed by the radiologist who read the x-ray and generated the x-ray report.

(This ER physician didn't generate an x-ray report with interpretation and findings. You're just seeing it mentioned in the ER document that the patient had an x-ray. Nothing in that note is separately billable for the x-ray.)
 
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The procedure code is 27840, so it doesn't seem that the sedation was bundled in with it.

Isn't there always a reporting physician? In some cases I needed to report the drug code. Does it depend on the department? For example, do ER physicians never report drug codes?
 
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Susan is correct, the facility will bill for most of that not the ER physician. It looks like this is for an outpatient test so that's where you are off is you are trying to bill facility things. I hope that makes sense :)
 
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Elund said:
So do I only bill facility things when the E/M category says "inpatient" or "facility"?
Click to expand...

On a physician claim, you only bill for services performed by that physician.

The facility would have a separate medical record and a separate medical claim. (In Practicode, it is unlikely that you'd encounter a facility record. My recollection from when I did Practicode is that it was all physician records. Some of those physician services may be rendered in a facility setting, but you're still viewing the physician record not the facility's record.)

The key thing to remember is that a physician is not going to bill for charges that are the facility's responsibility. In the facility setting, the physician isn't the one purchasing the drugs, supplies, or equipment.

The physician would only be billing for their professional time and expertise in the facility setting. For example, an E/M visit or a surgery they personally performed.
 
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