Transcript 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
1
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
2
Emergency Department E/M Codes
• 99281
• 99282
• 99283
• 99284
• 99285
• Critical Care 99291
– +99292
3
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.”
4
Medical decision making dictates the highest
level code that can be chosen –
Proper documentation
supports your choice.
5
ED E/M Codes
• 99281 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.
• 99282 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.
6
99283 and 99284
• 99283 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.
• 99284 ED visit for the evaluation and management of a patient,
which requires these three key components:
– a detailed history
– a detailed examination
– medical decision making of moderate complexity
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.
7
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.
8
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
9
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
10
Documentation Guidelines
HPI
ROS
PFSH
Exam
Level of
Service
1
0
0
1
99281
1
1
0
2
99282
1
1
0
2
99283
4
2
1
5
99284
4
10
2
8
99285
11
Medical Decision Making
12
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
13
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
14
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.
15
Critical Care
16
Critical Care Overview
• Evaluation and Management (E/M) Code
• Found in first section of CPT
• Reported using 99291
• Additional work reported with the add on code
+99292
17
Critical Care Overview
• Unlike other ED E/M codes, no specific key element
requirements
• Time based code
• Patient must meet certain clinical criteria
18
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
19
Organ System Failure
• Central nervous system
failure
• Circulatory failure
– Acute MI
• Shock
– Severe trauma
– Coagulopathy
• Renal failure
– New onset
– Hyperkalemia
20
• 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
21
“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
22
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
23
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
• 36000/36410/36415/365
91/36600
• Gastric Intubation
• 43752/91105
24
Critical Care:
“What is Not Included?”
• Endotracheal intubation 31500
• CPR 92950
• Triple Lumen Catheter insertion 36556
• EKG interpretation 93010
• Bill these separately
25
Critical Care Time Requirements
Critical Care Time
<30 minutes
Code
Appropriate E/M code
30-74
99291
75-104
99291, 99292
105-134
99291, 99292 X 2
26
Procedures
27
What is Included in a Procedure?
• Assess site/location of problem area
• Explain procedure
• Obtain consent
28
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
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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”
30
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
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Epistaxis Coding
• Anterior Epistaxis
– Limited Cautery/Packing 30901
– Extensive Cautery/Packing 30903
– Nasal Tampons 30903
• Posterior Epistaxis
– Packs/Cautery‐any method 30905
32
Abscess Drainage
• Simple or single
– Furuncle, paronychia
– Superficial
– Single
• Complex or multiple
– Probing
– Loculations
– Packing
33
Abscess Coding
• Simple or single
10060
• Complex or Multiple
10061
• Pilonidal Abscess
10080
• Peritonsilar Abscess
42700
34
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
35
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
36
Lacerations
• Codes are grouped anatomically
– 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
37
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
38
•
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.
39
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.
40
Staple and Suture Removal
• Reportable only when repair performed by
another group
• Vacation areas more common
• Report low level E/M
41
Foreign Body Removals
• Anatomic Location
• Depth of tissue penetration
• Technique of removal
– Irrigation
– Incision
– Dissection
42
Foreign Body Removal Coding
• Ear Foreign body 69200
• Nasal Foreign Body 30300
43
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
44
Coding Soft Tissue Foreign Bodies
• Simple 10120 simple incision made, FB removed with
forceps
• Complex 10121 requires moderate dissection,
perhaps X‐rays or C‐Arm
• Foot separate codes
– 28190 FB in SQ
– 28192 FB in deep tissues
45
Toe Nail Resection Reimbursement
• Avulsion of nail plate 11730
• Wedge excision, skin of nail fold 11765
• Excision of nail and nail matrix partial or
complete for permanent removal 11750
46
Cerumen Impaction
• Technique Employed
– Irrigation (included in the EM)
– Curettage
• MD Involvement
• Good Procedure Note
• 69210
47
Splints
• Physician Involvement
• Medicare
• Off the shelf
• Fiberglass/Plaster
• Fracture Care
48
Splints
• Replacement or initial application of splint/strap
(CPT® codes 29000 – 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
49
Splint Coding
• Long Leg 29505
• Long Arm 29105
• Short Leg 29515
• Short Arm 29125
• Finger 29130
50
Fracture Care
51
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
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Fracture Care Reporting
To code for fracture care services the Emergency
Physician must provide either “definitive” or
“restorative care."
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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
54
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 29515
• 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 29125
• Do not report Fx care
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Fractures Potentially Involving
ED Definitive Care
• Fingers
– No distinction between fingers or thumb
– Grouped by phalanx involved: proximal &middle vs distal
– 26720 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx,
finger or thumb; without manipulation, each
– 26750 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
– 28490 Closed treatment of fracture great toe, phalanx or phalanges; without
manipulation
– 28510 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
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Fractures Generally Involving
ED Definitive Care
• Clavicle
– 23500 Closed treatment of clavicular fracture
– Frequently involves a sling/sling & swath
• Strapping not reported separately with Fx care
• Rib
– 21800 Closed treatment of rib fracture, uncomplicated, each
– Frequently involves pain control, s/sx for follow up or IS
• Nose
– 21310 Closed treatment of nasal bone fracture without manipulation
– Frequently involves pain medication & decongestants
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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
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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 25605 closed treatment of distal radial
fracture
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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.”
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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
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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.”
62
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
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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
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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.
65
Dislocation Codes
• Use dislocation codes for any documented reductions
– Fingers and Toes
– Shoulders
– Hips
– Ankles
– Patella
– Mandible
– Elbow
66
Moderate Conscious Sedation
67
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
68
Moderate Conscious Sedation
• 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
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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.
• +99145: each additional 15 minutes.
– Add on Code
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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.
• +99150: each additional 15 minutes.
– Add on Code
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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
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MCS and Appendix G Issues
• Appendix G lists ~250 codes that bundle CS
• ED Important codes:
– 32551 chest tube insertion
– 33010 pericardiocentesis
– 33210 insertion transvenous pacemaker
– 36555 insertion pediatric (under age 5) central line
– 36568 insertion pediatric (under age 5) PICC line
– 92953 transcutaneous pacing
– 92960 elective cardioversion
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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
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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.
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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.
76
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.
77
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.
78
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.
79
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.
80
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.
81
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.
82
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
83
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
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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.
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