CPT® Coding for Emergency Departments

CPT® Coding for Emergency Departments
Materials prepared by: Michael A. Granovsky, M.D., CPC, FACEP Presented by: Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC

1995 vs. 1997 Documentation Guidelines
• Medicare allows physicians and providers to choose between the 95 and the 97 DGs, whichever set results in the greatest benefit • Many non‐Medicare payers follow Medicare documentation guidelines but for specific payer policy it is necessary for physicians to confirm their state regulations and the rules of each plan they bill. • In the ED setting, where general multi‐system exams are more common, the 1995 DGs will typically be more favorable to the physician • Exception‐ ophthalmologic illnesses and injuries – Tend to be focused on just 1 organ system

Emergency Department E/M Codes
• 99281 • 99282 • 99283 • 99284 • 99285 • Critical Care 99291 –

ED E/M Rules • No distinction made between new and established patients in the emergency department. • Emergency department is defined as: “An organized hospital‐based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day.”

Medical decision making dictates the highest level code that can be chosen – Proper documentation supports your choice.

ED E/M Codes • ED visit for the evaluation and management of a patient, which requires these three key components: – a problem focused history – a problem focused examination – straightforward medical decision making Usually, the presenting problems are self limited or minor. • ED visit for the evaluation and management of a patient, which requires these three key components: – an expanded problem focused history – an expanded problem focused examination – medical decision making of low complexity Usually, the presenting problems are of low to moderate severity.

99283 and 99284 • ED visit for the evaluation and management of a patient, which requires these three key components: – an expanded problem focused history – an expanded problem focused examination – medical decision making of moderate complexity Usually, the presenting problems are of moderate severity. • ED visit for the evaluation and management of a patient, which requires these three key components: – a detailed history – a detailed examination Usually, the presenting problems are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.

Definition 99285 99285 ED visit for the evaluation and management of a patient, which requires these three 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 Usually, the presenting problems are of high severity and pose an immediate significant threat to life or physiologic function.

CMS History Caveat You must document the reason history is not obtained and documented on the record. – NH patient with dementia – Postictal – Severe dyspnea (CHF or Asthma) 5 recognized sources for history: Family, nursing home staff/records, prior hospital charts EMS charts, EMS, personal physician ‐The physician must make reference to these notes

The “Emergency Medicine” Caveat
“If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstances which precludes obtaining a history.” CMS 1995 Documentation Guidelines

Documentation Guidelines
HPI ROS PFSH Exam Level of Service 1 99281 2 99282 99283 4 5 99284 10 8 99285

Medical Decision Making

Cautionary Note • Audit tools and coding references used by payers and practices can be varied and different • One audit tool may place a larger emphasis on the number of necessary differential diagnoses and list specific treatments and therapeutic options • The majority of industry accepted audit tools are reported to produce consistent findings greater than 95 percent of the time. However, as a precaution a coder should always contact the local Medicare Carrier to request any and all available coding guides, specifically relative to E/M audit tools before conducting training with a billing physician. • AAPC certification tests use the logic originally developed by the Marshfield Clinic and never asks a coder to make a determination on medical necessity beyond the definitions provided by the CPT, 95 and 97 DGs, and logics that are based on the Marshfield Clinic audit model

Medical Decision Making Scoring Systems
• Most use the Marshfield Clinic Type Audit Tool to expand on the Documentation Guidelines • Not an official part of the DGs • Tool used to score the overall Medical Decision Making • Evaluates 3 components: – Number of Diagnosis and Management Options – Amount - Risk

Medical Decision Making: Number of Diagnosis or Management Options
CPT® does not distinguish between new and established patients in the ED • New prob. No Additional Work-up • Patient seen and discharged • New prob. Additional Work-up planned • Admit, Transfer, OR, scheduled outpatient special testing or specifically scheduled follow‐up.

Critical Care

Critical Care Overview
• Evaluation and Management (E/M) Code • Found in first section of CPT • Reported using • Additional work reported with the add on code

Critical Care Overview
• Unlike other ED E/M codes, no specific key element requirements • Time based code • Patient must meet certain clinical criteria

Critical Care Definition
“A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition..” AMA/CPT® 2009

Organ System Failure • Central nervous system failure
• Circulatory failure – Acute MI • Shock – Severe trauma – Coagulopathy • Renal failure – New onset – Hyperkalemia • Hepatic Failure – Encephalopathy – Stroke • Metabolic failure – Toxic Ingestion (methanol) – Severe Acidosis • Respiratory Failure Pneumonia

Critical Care Requirements
• Clinical Requirement of high probability of deterioration • Time requirement • Minimum 30 minutes • Excludes separate procedures

“Full Attention and Physician Time”
• Time counted must be exclusively devoted to patient • Does not have to be continuous • Physician must document total time on chart • Must document that time involved in separately billable procedures was not counted toward CC time • Attestation with check box or fill in the blank OK

Critical Care Time: What Counts?
• Bedside patient care • Reviewing ancillary studies • Discussions with: – Family, rescue, nursing, physicians as related to care • Chart documentation and completion • Bundled Procedures – CXR

Critical Care Bundled Services
Cardiac Output – 93561/93562 CXR – 71010/71015/71020 Pulse Oximetry – 94760/94761/94762 Computer Data – 99090 • Transcut. Pacing 92953 • Ventilator Mgt 94002‐94004, 94660, 94662 • Vascular Access 36000/36410/36415/36591/36600 • Gastric Intubation 43752/91105

Critical Care: “What is Not Included?”
• Endotracheal intubation • CPR • Triple Lumen Catheter insertion • EKG interpretation • Bill these separately

Critical Care Time Requirements
Code <30 minutes Appropriate E/M code 30-74 99291 75-104 99291, 99292 99291, X 2

Procedures

What is Included in a Procedure?
Assess site/location of problem area Explain procedure Obtain consent

CPT® and Procedures CPT® Bundles the following:
– Local infiltration and digital block – Subsequent to the decision for surgery one related E/M…on the date of the procedure – Immediate post operative care – Writing orders and evaluation in the PACU – Typical post operative care

Medicare Minor Procedures
• Defined as global period < 10 days • Most have a clinically meaningful separate and distinct service to bill and add modifier 25 to E/M code • “Visits on the same day as a minor procedure by the same physician are included in the payment for the procedure unless a significantly separately identifiable service is also performed”

Medicare Major Procedures
• Defined as global period of 90 days • Typically fracture care and dislocations in the ED. • Use modifier 57 on the E/M ”Instruct billers to use modifier 57 (decision for surgery) to identify a visit that results in the decision to perform surgery.” MCM Section 4822

Epistaxis Coding • Anterior Epistaxis • Posterior Epistaxis
– Limited Cautery/Packing 30901 – Extensive Cautery/Packing 30903 – Nasal Tampons 30903 • Posterior Epistaxis – Packs/Cautery‐any method 30905

Abscess Drainage • Simple or single • Complex or multiple
– Furuncle, paronychia – Superficial – Single • Complex or multiple – Probing – Loculations – Packing

Abscess Coding Simple or single 10060 Complex or Multiple 10061
Pilonidal Abscess Peritonsilar Abscess

Paronychia vs. Finger Abscess
• Paronychia infection limited to tissue around the nail • Finger abscess involves the finger pad • More common now with community acquired MRSA

Dermabond Coding • Medicare: • Single layer alone use G0168
• Multiple layer with deep sutures intermediate repair code such as 12052 • Other Payers‐ always use laceration codes – Single layer face 12011 – Multiple layers face 12052

Lacerations • Codes are grouped anatomically • Complexity of repair:
– Face/ears/lips/mucous membranes – Scalp/neck/extremities • Complexity of repair: – Simple‐single layer – Intermediate‐layered closure – Complex‐creation of a defect, extensive undermining, retention sutures… • Extensive cleaning and removal of debris may elevate repair from superficial to intermediate

Complex Lac Repair • Not commonly used in ED • Consider when drain placed • Z and W advancement flaps uncommon • Extensive debridement of devitalized tissue associated with complex traumatic lacerations

Laceration Repair • Simple repair: the wound is superficial; involving primarily epidermis without significant involvement of deeper structures, and requires simple one layer closure. • Intermediate repair: the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers. Single‐layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.

Complex Repair Complex repair: the repair of wounds requiring more than layered closure, such as scar revision, debridement, (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a defect for repairs (eg, excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions.

Staple and Suture Removal
• Reportable only when repair performed by another group • Vacation areas more common • Report low level E/M

Foreign Body Removals • Anatomic Location
• Depth of tissue penetration • Technique of removal – Irrigation – Incision – Dissection

Foreign Body Removal Coding
Ear Foreign body 69200 Nasal Foreign Body 30300

Ocular Foreign Body Coding
• Location – Conjunctival • Superficial 65205 • Embedded 65210 – Corneal • No slit lamp 65220 • Requiring Slit lamp for removal 65222 • Rust Ring Burr Tx 65435

Coding Soft Tissue Foreign Bodies
• Simple simple incision made, FB removed with forceps • Complex requires moderate dissection, perhaps X‐rays or C‐Arm • Foot separate codes – FB in SQ – FB in deep tissues

Toe Nail Resection Reimbursement
• Avulsion of nail plate • Wedge excision, skin of nail fold • Excision of nail and nail matrix partial or complete for permanent removal 11750

Cerumen Impaction • Technique Employed • MD Involvement
– Irrigation (included in the EM) – Curettage • MD Involvement • Good Procedure Note • 69210

Splints • Medicare • Off the shelf • Fiberglass/Plaster
• Physician Involvement • Medicare • Off the shelf • Fiberglass/Plaster • Fracture Care

Splints • Replacement or initial application of splint/strap (CPT® codes – 29799) • Use E/M code with cast/splint/strap code • For Medicare must be applied by Physician • If using Fracture care code splint service is bundled

Splint Coding • Long Leg • Long Arm • Short Leg • Short Arm • Finger 29130

Fracture Care

ED Physicians and Fracture Care
• Emergency Physicians provide important and meaningful fracture care • Often the first to see, treat, and stabilize injuries involving fractures • American College of Emergency Physicians (ACEP) strongly supports the reporting of fracture care • CPT® and Medicare (CMS) recognize the provision of fracture care by ED physicians

Fracture Care Reporting
To code for fracture care services the Emergency Physician must provide either “definitive” or “restorative care."

Definitive Care • The ED physician provides the same care as the orthopedist – Must be the same – Not a temporary measure but the same ultimate care provided by the specialist • Clinically fractures require a spectrum care: • Strictly supportive measures and pain control • Splinting • Casting • Operative fixation

Definitive Care Requirement Not Met
• If the orthopedist is going to place a cast • Distal fibula fracture Tx short leg splint • Orthopedist will place a cast • Code for the short leg splint • No Fracture Care Code • Moderately displaced 5th metacarpal fracture with rotational deformity • Volar short arm splint place in the ED • Orthopedist Tx in OR with a pin • Report the splint code • Do not report Fx care

Fractures Potentially Involving ED Definitive Care
• Fingers – No distinction between fingers or thumb – Grouped by phalanx involved: proximal &middle vs distal – Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each – Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation each • Toes – No distinction between proximal and distal phalanx – Grouped by involvement of great toe vs other toes – Closed treatment of fracture great toe, phalanx or phalanges; without manipulation – Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each If reporting the fracture care the splinting or strapping code is not separately coded

Fractures Generally Involving ED Definitive Care
• Clavicle – Closed treatment of clavicular fracture – Frequently involves a sling/sling & swath • Strapping not reported separately with Fx care • Rib – Closed treatment of rib fracture, uncomplicated, each – Frequently involves pain control, s/sx for follow up or IS • Nose – Closed treatment of nasal bone fracture without manipulation – Frequently involves pain medication & decongestants

Definitive Care Rarely Provided for Longer Bones
• Most EDs Do not use fracture codes for: – Hips – Femurs, Tibia, Fibula – Humerus – Elbow – Forearm –Ankle and Calcaneus – Metacarpal and Metatarsal • Rarely provide definitive care

Restorative Care • Restorative care is provided any time the ED physician manipulates the bones – Reduce the fracture – Restore or improve anatomic positioning • The ED physician manipulates a distal radius (Colles) fracture – Report code closed treatment of distal radial fracture

CPT® Definitions Open and Closed Fractures
• Closed treatment: “specifically means that the fracture site is not surgically opened (exposed to the external environment and directly visualized).” • Open treatment: “is used when the fractured bone is either (1) surgically opened (exposed to the external environment) and the fracture (bone ends) visualized and internal fixation may be used or (2) the fractured bone is opened remote from the fracture site in order to insert an intramedullary nail across the fracture site.”

Open vs. Closed Treatment
• This is a description of the technique used to treat the fracture, not the fracture itself. • Even if the fracture itself is open the ED physician likely did not provide open fracture care. • ED physicians almost never perform open treatment of a fracture • ED fracture care involves closed treatment

Modifier 54 CPT® Definition
Surgical Care Only: “When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier 54 to the usual procedure number.”

Modifier 54 Assignment • Placed on the fracture care CPT® code • The ED physician is providing the operative care only for these fractures • Signifies that the ED physician is not providing the post operative follow up care

Fracture Care E/M Modifiers Medicare Rules
• Medicare construct • Global Surgical package – Minor procedures (0‐10 day global) • Laceration repair – Major procedures (>10 day global) • Fracture Codes have a 90 day global • For major procedures Medicare requests applied to the E/M

Fracture Care Codes “Without” vs. “With Anesthesia”
• The AMA and CPT® have stated that the “with anesthesia codes” are to be used in the Operating Room Setting with general anesthesia. • These codes do not apply to the ED setting. • Even if Moderate Conscious Sedation or Deep Sedation employed report the “without anesthesia” codes.

Dislocation Codes • Use dislocation codes for any documented reductions – Fingers and Toes – Shoulders – Hips – Ankles – Patella – Mandible – Elbow

Moderate Conscious Sedation

• Patient responds purposefully to verbal commands with light tactile stimulation • No interventions are required to maintain a patent airway • Spontaneous ventilation is adequate • Cardiovascular function is maintained

• Codes divided into 2 groups: • MCS provided by the same physician who is performing the procedure – Requires an independent trained observer • MCS provided by a physician in support of a second health care provider performing the procedure • Each group further delineated based on age of patient and time increments

MCS Same Physician: 99143, 99144, 99145 • Moderate sedation by same doctor performing the procedure • 99143: Under 5 y.o. ‐ first 30 minutes. • 99144: 5 y.o. and over ‐ first 30 minutes. • : each additional 15 minutes. – Add on Code

MCS Different Physician: 99148, 99149, 99150
• Moderate sedation by different doctor from the one performing the procedure • 99148: Under 5 y.o. first 30 minutes. • 99149: 5 y.o. and over, first 30 minutes. • : each additional 15 minutes. – Add on Code

MCS: Intra Service Time
• Intra‐service time starts with the administration of the sedation agents • Required continuous face‐to‐face attendance • Ends at the conclusion of personal contact by the physician providing the sedation

MCS and Appendix G Issues
• Appendix G lists ~250 codes that bundle CS • ED Important codes: – chest tube insertion – pericardiocentesis – insertion transvenous pacemaker – insertion pediatric (under age 5) central line – insertion pediatric (under age 5) PICC line – transcutaneous pacing – elective cardioversion

MCS and Appendix G Codes
• Do not report MCS for an Appendix G procedure when only a single physician involved • Do not report codes 99143‐99145 with Appendix G procedures • You may report MCS for an Appendix G procedure when provided by a different physician other than the one performing the procedure • Do report codes 99148‐99150 with Appendix G Procedures

Fracture Care Example FRACTURE CARE: Performed by attending. Prior to procedure, capillary refill normal. Compartment is normal. Distal sensation is intact. Distal motor function is normal. Left wrist fracture noted. Closed treatment of colles wrist fracture without manipulation completed. X-ray ordered. Short arm post mold applied. Material used for splinting is plaster. Orthopedic device applied in position of comfort. Post splinting neurovascular check. Capillary refill normal, distal sensation is intact, distal motor function is normal. Patient tolerated procedure well.

Splint Coding Example Intervention Xray: Right tibia fibula and foot negative for acute bony injury Immobilization was achieved by the application of OCL stirrup short leg splint applied by ERMD Immobilization device was then check to assure good neurovascular flow and effectiveness of positioning by me before the patient was discharged Crutches dispensed. Crutch walking safely with good use of crutches Follow up: Instructions given to follow up with MD or orthopedics in 4-5 days. May return to ER or orthopedics sooner for worsening symptoms.

Incision and Drainage Example
42-year-old man presents to the ED with multiple small abscesses on his lower back. The areas are localized, erythematous, fluctuant and swollen. The affected areas were prepped with Betadine. A 1% Lidocaine local block was used on all four areas. The abscess was incised with a #11 blade, positive moderate purulent material was expressed from all areas, hemostat used to breakup loculations, cavities were irrigated until clear drainage. Incision sites packed with vaseline gauze Areas were covered with a sterile nonadherent dressing. Patient tolerated the procedure well.

Laceration Repair Example
Procedure: Laceration repair description: 13 cm linear laceration on right upper forehead, shape linear. Wound prep: Betadine, Wound irrigation: Saline, Foreign body removal: yes, multiple pieces of dirt and gravel removed by hand and irrigation, re-explored and no dirt or FBs seen. Local anesthesia: Lidocaine:1%, with epinephrine, 10cc sq Repair: 2 layers, deep layer repaired with simple interrupted absorbable 3-0 vicryl sutured and skin layer repaired with staples, 13 staple.

Moderate Conscious Sedation Example
The patient was prepared in Room 2 for procedural sedation and reduction of his upper extremity fracture. Patient was given 30 mg of ketamine IV, approximately 1.5 mg/kg by me. This had good effect as the reduction was tolerated reasonably well and uncomplicated. Patient was thoroughly monitored during the reduction, with no complications. The reduction was performed by Dr. O of orthopedics MCS by ERMD. Patient was recovered in emergency department, discharged in the care of his family in improved and stable condition. He will follow up with orthopedics as directed. Sedation time: 30 minutes

CPT® CPT® copyright 2009 American Medical Association. All rights reserved. Fee schedules relative value units schedules, units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT® is a registered trademark of the American Medical Association.

CPT® Coding for Emergency Departments

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