Vol. 17 Issue 22
Coding the Emergency Room Visit
E&M exam documentation guidelines allow for the use of either the 1995 or 1997 guidelines, whichever is preferable to the provider.
Chief Complaint: Scalp laceration
History of Present Illness: This 82-year-old female, severely demented nursing home patient, presents to the emergency department (ED) by ambulance following a fall in the nursing home in which she sustained a scalp laceration. The patient is severely demented and unable to provide any meaningful history. Her only response to questions or examination is to cry out.
Physical Examination: White female in no acute distress. Opens eyes and looks at examiner, but does not verbalize. There is no obvious facial trauma present. There is a 4.0 cm scalp laceration involving the right parietal area, parallel and near the mid-line. There is no palpable bony tenderness or skull deformity.
HEENT:The pupils are equal and react to the light.
Neck:There is no tenderness to palpation, although the patient cries and appears to be in pain when the neck is gently moved. The patient has a right torticollis with generalized neck stiffness present.
Heart:Regular rhythm and rate.
Neurological:The patient spontaneously moves all extremities. She does not cooperate with meaningful sensory or motor testing, however.
Diagnostic Studies:CT scan of the brain was negative.
Procedure:Laceration repair. Scalp laceration was cleaned with Betadine and normal saline. 1% Lidocaine local anesthetic was used. The scalp was repaired with 5-0 Nylon.
Diagnosis:4.0 cm scalp laceration, repaired.
Plan:Keep the wound clean and dry. Watch for infection. Return the patient to the ED if problems arise.
Hospital Rationale and Codes
The patient sustained a laceration of the scalp. There were no foreign bodies and no deformities of the skull. The laceration was clean and closed in one layer. In the CPT manual index, refer to the term Skin then Wound Repair and Simple É12001Ð12021. After reading the descriptions of the codes in this range, you will see that the following is the correct code:
12002Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm
To describe the evaluation and management (E&M) level of visit, choose a code from the 99281Ð99285 range. The code you choose will depend upon your facility-specific criteria. Attach the following modifier to the E&M code chosen.
25Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service
The following diagnosis codes should also be assigned to the hospital claim:
873.0Open wound of scalp, uncomplicated
Physician Rationale and Codes
According to Medicare documentation guidelines, if the history cannot be obtained from the patient or other person present, this fact should be documented, as the physician did above. With no history from the patient, the level of E&M code is based on the examination and medical decision-making only.
E&M exam documentation guidelines allow for the use of either the 1995 or 1997 guidelines, whichever is preferable to the provider. Using the 1997 guidelines, the documentation contains 10 bullets and thus would be classified into expanded problem-focused. Using the 1995 guidelines, seven body areas or systems can be identified, classifying the exam as detailed. In this case, the 1995 guidelines are the best choice.
The medical decision-making comes out to be moderate complexity. There is one new problem without additional workup, moderate risk and minimal amount of data to review.
To assign the codes, look in the index under Evaluation and Management then Emergency Department 99281-99288. A review of these codes and verification of the key components will lead you to code 99284. As stated in the CPT manual, three key components are required to assign 99284: a detailed history, a detailed examination and medical decision-making of moderate complexity. To indicate that this was a separate service in addition to the procedure, you must assign the following modifier to code 99284:
25Significant separately identifiable E&M service by the same physician on the same day of the procedure or other service
The next code you must find is the repair code. As in the hospital coding, go to the index and check under Skin, then wound repair and simple 12001-12021. Also like the hospital assignment, the correct code is 12002. For the physician component, you will need to assign the following modifier to indicate that surgical care only was delivered.
54 Surgical care only
The following diagnosis codes should be assigned to the physician claim:
873.0Open wound of scalp, uncomplicated
Margaret Pitotti is a senior health care consultant with Medical Learning Inc. (MedLearn®), St. Paul, MN.