Account for Complex Procedures in the ED
Accurate reporting requires identifying all procedures performed beyond the initial E/M.
By Sarah Todt, RN, CPC, CPMA, CEDC
Physicians in the emergency department (ED) very often perform procedures in addition to evaluation and management (E/M) services. Integumentary procedures such as laceration repair, burn treatment, or incision and drainage are common, as are orthopedic procedures such as splint placement or fracture reductions. Critically ill or injured patients may require more complex procedures to stabilize or treat life-threatening conditions. Accurate reporting of ED encounters is reliant on coders not only to review the documentation, but also to be aware of the presentations and symptoms typically associated with conditions that require additional procedures. The following are some common ED scenarios and tips for what you should look out for.
It’s no surprise that a patient with respiratory failure may require endotracheal intubation (31500 Intubation, endotracheal, emergency procedure) for airway support. Patients with other clinical conditions may also require intubation for airway protection. Such conditions may include drug overdose, sepsis, some neurological conditions, etc. The clinical note may reflect symptoms such as hypoxia, tachypnea, and respiratory distress.
Documentation of the intubation procedure may include “endotracheal” or “nasotracheal intubation” and a notation of the tube size (e.g., 7.0) and location (e.g., 22 cm at the lip). There generally will be documentation stating the CO2 indicator or X-ray confirmation of placement. There is no additional code for using sedation, which may be documented as “RSI” (rapid sequence induction), or for using a scope (e.g., GlideScope®) to assist in the placement of the endotracheal tube. Be sure to review the documentation for a procedure note when there is notation of “patient placed on ventilator.”
Placing a Central Line
Very ill patients, including those with sepsis or gastrointestinal (GI) bleeding, may develop hypotension requiring fluid resuscitation or vasoactive medications, such a dopamine or Levophed®. These medications generally require central vascular access for the provider to place a central line.
Central lines may be single or multiple lumen, and are typically placed in the subclavian, internal jugular, or femoral veins. Proper coding is 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older. Ultrasound is frequently used to assist in the placement of central lines, and is a separately billable service using add-on code +76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure).
Note that a line placed in the external jugular vein is considered a peripheral line and is reported using CPT® 36600 Arterial puncture, withdrawal of blood for diagnosis. This service is not separately billable if the physician reports critical care (e.g., 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).
Patients who are treated with vasoactive medications require frequent monitoring of hemodynamic status. An arterial line may be placed for continuous monitoring of the patient’s blood pressure. Arterial lines are most frequently placed in the radial artery, but also can be placed in the brachial, femoral, or other arteries. Look for documentation stating “art line placed by me.” Arterial line placement is coded 36620 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous, and should not be confused with a one-time blood draw for arterial blood gas.
Patients presenting with complex neurological conditions may undergo a lumbar puncture. In this procedure, a needle is inserted (typically in the L3-L4 space) and a small amount of cerebral spinal fluid is obtained. Within the provider’s documentation, you’ll see a notation of the tube number and a description of the fluid obtained (multiple tubes will be obtained). Lumbar puncture is reported with CPT® 62270 Spinal puncture, lumbar, diagnostic. This procedure is generally performed to rule out meningitis or subarachnoid hemorrhage. Expect to see documentation of this procedure if the provider documents meningitis or SAH (subarachnoid hemorrhage) as a differential diagnosis.
Patients with arrhythmias occasionally require cardioversion, which may be performed chemically or electrically. Cardioversion procedures can be a coding challenge because not all represent a separately billable service.
Chemical cardioversions are performed when an antiarrhythmic medication (e.g., adenosine, diltiazen, or amiodarone) is given intravenously to treat supraventricular tachycardia, atrial fibrillation with rapid ventricular response, or other wide complex tachycardia. Chemical cardioversion is not a separately billable service; the treatment is included in the E/M service. Chemical cardioversion may be reported as a critical care E/M service if the provider’s documentation supports it.
Electrical cardioversion involves a physician applying a shock to convert to a rhythm, and it is a separately reportable service, coded 92960 Cardioversion, elective, electrical conversion of arrhythmia; external, when certain criteria are met. The code description states “elective cardioversion,” which indicates it’s not an emergent procedure.
Documentation indicating the procedure was elective would include a noted discussion with the patient for consent and sedation. Another indication that the procedure was elective is a notation of synchronization, which involves a shock delivered at a specific time. The non-emergent status allows for the additional time. Emergent cardioversion or defibrillation is not a separately reportable service. Defibrillation is included in the cardiopulmonary resuscitation service.
Documentation, Understanding Are Key
Your ability to recognize presentations and symptoms typically associated with conditions that require additional procedures will enable you to purposely review documentation. If a notation is unclear or seems to be lacking, query the provider—do not make assumptions. Encourage providers to write clear procedure notes, separate from E/M documentation, to empower you to capture all services performed. Finally, to assure an appropriate claim, be aware of which services are billable and which are included in the E/M service.