procedures in the ed · procedures in the ed most $$$ ed cpt codes (not including e&m codes)...

1

Procedures in the ED

Most $$$ ED CPT Codes(not including E&M codes)

93010 Electrocardiogram report31500 Insert emergency airway36556 Insert non-tunnel CV cath92950 Heart/lung resuscitation CPR12001 Repair superficial wound(s)12002 Repair superficial wound(s)12011 Repair superficial wound(s)12013 Repair superficial wound(s)10061 Drainage of skin abscess11042 Debride skin/tissue30901 Control of nosebleed

Interpretations

• Per CPT “the actual performance and/or interpretation of any diagnostic tests or studies performed in conjunction with a patient’s visit should be reported inaddition to the appropriate E&M service”.

• EKGs X-rays Ultrasounds

MCEP Straight Talk 2018

www.ERcoder.com

2

CMS Carriers Manual

• Distinguish between an "interpretation and

report" of an x-ray or an EKG procedure

and a "review" of the procedure.

CMS Carriers Manual

• The review of the results is already

included in the emergency department

evaluation and management (E/M)

payment.

CMS Carriers Manual

• For example, a notation in the medical records

saying “fx-tibia” or EKG-normal would not suffice

as a separately payable interpretation and report

of the procedure and should be considered a

review of the findings payable through the E/M

code.


www.ERcoder.com

3

CMS Carriers Manual

• An “interpretation and report” should

address

• the findings,

• relevant clinical issues, and

• comparative data (when available).

EKG Interpretations

Suggestion for defining EKG “interpretation”• An EKG interpretation should include at least 3

of the following 6 elements. – Rhythm – Rate– Axis– Intervals– ST Segment change– Comparison to a prior EKG– Summary of clinical condition

EKG Interpretation

•Billable EKG interpretation:

EKG NSR, no ST changes, unchanged from prior EKG with no evidence of ischemia.

•Unbillable EKG interpretation:

EKG normal.


www.ERcoder.com

4

Signing EKG Tracing

Most payers want more than a signature on the printout from the machine.

• " An ECG that has been interpreted by a computer alone is not recognized as a properly interpreted ECG.“

• "Any computer generated ECG interpretation must be over-read, modified as appropriate and signed by the interpreting physician."

National Government Services

• "Electrocardiograms and Interpretation reports (computer generated reports): It is not adequate simply to sign a computer-generated report. It is expected the physician would read, measure, interpret, prepare a report of, and sign the reading of the EKG.

Ultrasounds in the ED

• ACEP policy promotes the immediate availability of ultrasound examination and interpretation on a 24-hour-a-day basis for ED patients and identifies emergency ultrasound performance as a standard emergency physician skill that should be delineated in the emergency physician’s clinical privileges.

• It stands to reason that emergency physicians should be appropriately reimbursed for providing emergency ultrasound procedures in the emergency department.


www.ERcoder.com

5

Common ED ultrasounds:

FAST Exam

• 93308 Echocardiography, transthoracic, real-time with image documentation (2D) or without M-Mode recording; follow-up or limited.

• 76705 Ultrasound, abdominal, B-scan and/or real time with image documentation limited (e.g. single organ, quadrant, follow- up)

• EFAST will add 76605 Ultrasound, chest (includes mediastinum), real time with image documentation

Abdominal Aortic Aneurysm

• 76775 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), B-scan and/or real time with image documentation; limited.

• 76705 Ultrasound, abdominal, B-scan and/or real time with image documentation limited (e.g. single organ, quadrant, follow- up)


Pericardial Effusion and/or Cardiac Tamponade

• 93308 Echocardiography, transthoracic, real-time with image documentation (2D) or without M-Mode recording; follow-up or limited.

Pelvic (Pregnant)

• 76815 Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses

• 76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal


Pelvic (Not Pregnant)

• 76857 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (e.g., for follicles)

• 76830 Ultrasound, transvaginal

• Evaluation of Kidney Disease

• 76775 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), B-scan and/or real time with image documentation; limited.


www.ERcoder.com

6


Extremity

• 76882 Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific.

– Do not report with joint injection/drainage. Report new combo code for w/ultrasound


Evaluation of Gall Bladder Disease

• 76705 Ultrasound, abdominal, B-scan and/or real time with image documentation limited (e.g. single organ, quadrant, follow-up)

Ultrasound Guidance Procedures

• 76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)

• 76942 Ultrasonic guidance for needle placement (e.g. biopsy, aspiration, injection, localization device) imaging, supervision and interpretation


• Ultrasound examinations are “complete” or “limited” in their code definitions.

– A complete study - an attempt is made to visualize and diagnostically evaluate all of the major structures within the anatomic description.

– A limited study - addresses only a single quadrant or a single diagnostic problem.


www.ERcoder.com

7


• For those anatomic regions that have "complete" and "limited" ultrasound codes, note the elements that comprise a "complete" exam. – A complete ultrasound examination of the abdomen

(76700) consists of B mode scans of: liver, gall bladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava including any demonstrated abdominal abnormality.

• The report should contain a description of these elements or the reason that an element could not be visualized (e.g., obscured by bowel gas, surgically absent etc.)


• The procedures that are specified as complete usually represent the type of ultrasound typically performed by a consultant or specialist.

• Emergency physicians most frequently conduct limited ultrasound examinations in which a focused diagnostic problem is addressed and diagnostic results are used to guide subsequent evaluation or treatment.


• All diagnostic ultrasound examinations require permanently recorded images with measurements, when such measurements are clinically indicated.

• A final, written report must be issued for inclusion in the patient's medical record.


www.ERcoder.com

8


• To report an ultrasound interpretation all of the following are required.

– thorough evaluation of organ(s) or anatomic region

– image documentation

– written report


• In an ideal report would show the following documented for ultrasound interpretations.- Description of the structures or organs studied

and an interpretation of the findings.

- The condition or diagnosis that supports the medical necessity of the diagnostic test.

- Indication as to who performed the procedure.

- Indicate whether the study was a limited or complete examination.

- Indication that a permanently recorded image was saved or printed


• Experience has taught us that documentation is not always ideal.

• A coding policy needs to set a baseline for the lowest level of documentation that would accepted to assign an ultrasound code compared to the ideal documentation.


www.ERcoder.com

9


• An interpretation that describes the structures or organs studied and an interpretation of the findings.

– At a minimum the report should specify the body area or organ studied and the EDMDs findings.

• The condition or diagnosis that supports the medical necessity of the diagnostic test.

– If not specifically indicated in the report the patients presenting problem or complaint related to the study will be sufficient.


• Indication as to who performed the procedure.

– If the report is documented by the EDMD assume that the ultrasound was performed by that EDMD unless the chart states otherwise.

• If a resident performs the ultrasound under the supervision of an EDMD, the EDMD must document that they have personally reviewed the image and the resident’s interpretation and either agrees with it or edits the findings.

• Medicare does not pay for an interpretation if the teaching physician only countersigns the resident’s interpretation.


• Indicate whether the study was a limited or complete examination.– Unless otherwise documented, assume that it was

limited for those studies that have a limited vs. complete code.

• Indication that a permanently recorded image was saved or printed.– Some facilities have a policy that all ultrasounds will

have a permanent image placed in the patients file. Absent such a policy each note should indicate a that there is a permanent image saved.


www.ERcoder.com

10

Lacerations

The repair of wounds may be classified as:

• Simple

• Intermediate

• Complex

Procedure note should reflect depth, length and location of repaired wound.

Simple Lacerations

• Simple repair is used when the wound is superficial ; e.g., involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure .

Intermediate Lacerations

• Intermediate repair includes the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure .

• Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair .


www.ERcoder.com

11

Simple vs Intermediate

• 12001 Simple 2.5cm < - 1.29

• 12031 Intermediate 2.5 cm < - 4.34

Wound Repairs w/ tissue adhesive

• Wound closure utilizing tissue adhesives only (G0168)

• FDA data shows that the time needed to close a wound with tissue adhesive is, on average, one quarter of the time needed to close a wound with traditional methods (including use of wound closure tapes).

Wound Repairs w/ tissue adhesive

For Medicare

• Wound closure w/Dermabond only:

– Use G0168

• Wound closure w/Dermabond and sutures:

– Use appropriate CPT code.

For All other payers

– Use appropriate CPT repair codes.


www.ERcoder.com

12

40650 - Repair lip, full thickness; vermilion only

• Important for the coder to recognize when this procedure has been performed in the ED.

• More important for a coder to recognize when the procedure performed by the emergency physician does not rise to the level described by this code.


• Coders will frequently focus on the vermilion border language in the code descriptor and lose sight of the fact that the code descriptor specifies a full thickness repair.

• Single layer or simple repairs that happened across over the vermilion border do not rise to the level necessary to report 40650.


• Laceration does cross into the vermilion border.

• Depth and complexity of the injury do not meet the requirements of a full thickness laceration described by CPT code 40650 and would most accurately be coded with a 1201x CPT code.


www.ERcoder.com

13


• When asked about the use of this code for a single repair that extends beyond the vermilion, CPT assistant responded with "Code 40650, Repair lip, full thickness; vermilion only, identifies the repair of a laceration that involves the full thickness of the lip and the vermilion border."


• In this diagram, the laceration and the repair seem to be consistent with the CPT description of 40650 as well as this Coder's Desk Reference explanation of the procedure "The physician repairs a full sickness laceration of the lip. The tissues of the vermilion border are closed with layered sutures.”

Foreign Body Removals

• Anatomic Location

• Depth of tissue penetration

• Technique of removal• Irrigation• Incision• Dissection


www.ERcoder.com

14

Foreign Body Eyes

• Conjunctival– Superficial - 65205– Embedded – 65210

• Corneal– No slit lamp - 65220– With Slit lamp - 65222

• The conjunctiva is a mucous membrane that covers the sclera and the inside of the eyelids.

• The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber.

Foreign Bodies

• Ear Foreign body – 69200

• Nasal Foreign Body - 30300

Many techniques are available, and the choice depends on the clinical situation, the type of foreign body suspected, and the experience of the physician. Options include water irrigation, forceps removal (e.g., alligator forceps), cerumen loops, right-angle ball hooks, and suction catheters.

Impacted Cerumen

If any one or more of the following are present, cerumen should be considered ‘impacted’ clinically:

– Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.

– Qualitative considerations: Extremely hard, dry, irritative cerumencausing symptoms such as pain, itching, hearing loss, etc.

– Inflammatory considerations: Associated with foul odor, infection, or dermatitis.

– Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills.”


www.ERcoder.com

15

Impacted Cerumen

If the wax is truly impacted, its removal can be reported if performed by a physician.

69209 - using irrigation or lavage.

69210 - via suction, a cerumen spoon, forceps or other instrumentation. -

Soft Tissue Foreign Bodies

• 10120 - Incision and removal of foreign body, subcutaneous tissues; simple

•

• 10121 - Incision and removal of foreign body, subcutaneous tissues; complicated


• Foreign bodies that are deep or complicated may be more accurately coded with the site specific codes.

• Arm (upper and lower)

• elbow

• foot

• hip

• leg (upper only)

• shoulderNot Finger - 26705 = arthrotomy

“cutting into joint.”


www.ERcoder.com

16


• Cast cutter was used to remove shoe through which nail was embedded. Following placement of a nerve block, the nail was then cut at the surface of the foot with bolt cutter and removed with steady pulling, with remaining nail fragment traveling from plantar to dorsal foot surface.

28190 - Removal of foreign body, foot; subcutaneous

Soft Tissue Fishhooks

• String Technique

• Retrograde Technique

No applicable CPT codes


Needle Cover Technique


www.ERcoder.com

17


• Advance Technique


• Advance and

• Cut Technique

Epistaxis

• 30901 - Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method

• 30903 - Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method

• 30905 - Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial

90 %


www.ERcoder.com

18

Epistaxis Simple vs. Complex

30901 – “simple”

• Limited packing - cotton ball or gauze

• Silver nitrate cautery for ~10 seconds

30903 – “complex”

• Multiple attempts limited packing

• Multiple attempts cautery

• Extensive packing

– Complete occlusion of nasal cavity



Rhino Rocket or Merocel Dressing

When in place and in contact with moisture, the foam material swells to 6 times its compressed diameter.


www.ERcoder.com

19


Incision and Drainage

• Simple or single - 10060– Furuncle, paronychia– Superficial– Single

• Complex or multiple - 10061– Probing– Loculations– Packing– Drain

Abscesses that are deep or complicated may be more accurately coded with the site specific codes.

• 10160• 21501• 23030• 23031• 23930• 23931• 25028• 25031• 26010

• 26011• 26990• 26991• 27301• 27603• 30020• 40800• 40801• 41000

• 41005• 41800• 42700• 46050• 56420• 69000• 69005• 69020


www.ERcoder.com

20

Coding Orthopedic Care in the ED

• The key issue in coding orthopedic

treatment in the ED is whether the

treatment is “supportive” or "restorative".


• Splinting a fracture that will require reduction or other additional treatment at a later time is considered "supportive" or temporary.

• The appropriate coding would be to code only for splint placement if supported by documentation.


• If the fracture is definitively treated by splinting or other care provided in the ED, the treatment is considered "restorative" or definitive.

• The appropriate coding would be to code for fracture care if supported by documentation.


www.ERcoder.com

21


• For Medicare patients the ED physician must personally place the splint/cast in order to code for the fracture care or splint placement.

• For non-Medicare patients the emergency physician must either apply the splint/cast or for some payers it is acceptable for the physician to perform a post-placement evaluation of the application and bill for the service.


• Clear physician documentation is crucial to accurate coding for orthopedic services in the ED.– Displaced Fractures

• Was the fracture manipulated?• Exactly where is the fracture located?

– Fx radius = 25500, 25505, 25510, 25515, 25520, 25525, 25526, 25530, 25535, 25560, 25560, 25565, 25565, 25574, 25575, 25600, 25605, 25611 ,25620

– Fracture/Dislocation at or close to a joint• If there is a reduction is it of the displaced fracture or

the dislocated joint?


• Non-Displaced Fractures• What treatment was rendered in the ED?

• Who performed the placement of a cast/splint?

• Is there a post placement evaluation of a cast/splint?

• Is this care the definitive treatment of the fracture?– If yes how is the coder to know?

» Follow-up timeline

» Follow-up physician


www.ERcoder.com

22

ED Fracture Policy• Displaced Fractures –

– Code fracture care if the EDMD manipulates the fracture.

• Non-Displaced Fractures -

– Medicare• Code fracture care if the EDMD documents that

they placed splint/cast• Non-Medicare

• Code fracture care if the EDMD documents that they placed splint/cast

• Code fracture care if the EDMD documents that the splint/cast was placed under their supervision or if the EDMD documents a post placement evaluation of the splint/cast.

ED Fracture Policy

• DO NOT report fracture care for non-displaced fracture if the patient is instructed to follow-up with Ortho.

• DO NOT report fracture care for non-displaced fracture if the patient is instructed to follow-up in less than 48 hours.

• DO NOT report fracture care for non-displaced fracture if the treatment is a premade/off the shelf splint.

ED Splints

• Splint Placement - If the procedure does not qualify as fracture care, code the appropriate splint code if:– Medicare - The EDMD places the splint.

– Non-Medicare - The EDMD performs a post placement evaluation of the splint.

• DO NOT report splint placement if the treatment is a premade/off the shelf splint.

• DO NOT report splint placement if also reporting fracture care.


www.ERcoder.com

23


• Non-Displaced Distal Radius Fracture

– 25600 – 8.48

• Short Arm Splint

– 29125 – 1.09

What exactly is Moderate Sedation?

• Moderate Sedation is a drug induced depression

of consciousness.

• The patient maintains the ability to respond

purposely to verbal direction or verbal direction

either alone or accompanied by light tactile

stimulation.

• Interventions are not required to maintain the

patient’s airway.

Moderate Sedation

• For coding, there are 2 groups of codes that can be reported. – When the MS is provided by the same

physician performing the procedure that requires the sedation.

– When the MS is provided in support of another physician performing the procedure that requires the sedation.

– Each category is separated by codes for under age 5 and over age 5.


www.ERcoder.com

24

CPT 2017

• New for 2017. Intra-service time thresholds have dropped from 30 minutes to 15 minutes.

• There is a code for “initial 15 minutes’ intra-service time” and then an add on code for “each additional 15 minutes of intra-service time”.

MS Documentation

• To report the moderate sedation the EDMD

must document at least 10 minutes of intra-

service time.

• To qualify for the additional 15 minute code,

you still need to pass the half way point of

the extra 15 minutes (23 minutes).

MS Documentation

• Intraservice starts with the administration of

the sedation agent,

• Continues during constant face to face

attendance,

• Ends at the conclusion of personal contact

by the EDMD.


www.ERcoder.com

25

MS Documentation

• Once the EDMD personal contact is broken

the clock on reportable MCS time stops.

• Re-assessment of the patient and recovery

are not included in intraservice time.


www.ERcoder.com

procedures in the ed · procedures in the ed most $$$ ed cpt codes (not including e&m codes)...

Documents