Case Study:
Coding for a Patient with Multiple Injuries Without Sufficient Documentation of Procedures
Published on Mon Feb 01, 1999
by Caral Edelberg
ECA Consulting Editor
Editors Note: In this issue of ED Coding Alert, we introduce a new feature: the case study. In this and upcoming issues, we will take a typical patient chart or specific coding dilemma and guide readers through a step-by-step decision-making process to arrive at a solution. If you have a case study you would like to submit for consideration, please fax to 800/508-2592.
No matter how many coding guides, supplements and resources you collect, it seems there are always coding dilemmas that just wont fit neatly into the scenarios described in CPT or presented in the coding seminar your entire department just attended.
In this column, we will examine the case of a motor-vehicle accident (MVA) victim who presents to the ED with multiple lacerations. We will discuss the process taken to arrive at the proper evaluation and management (E/M) level to be coded and recommend which procedure codes should be used. (Please refer to the patient chart at right for the available documentation.)
Coding Discussion
First, remember that the primary function of coding is to translate the available documentation into the accurate codes. When in doubt, a coder has two options: seek additional clarification from the provider; or, code from the documentation as is. The latter choice often results in a bill coded for a lower level of service than may have been provided. However, a good coder never assumes that a service was provided by trying to read into the documentation when no supporting evidence exists. When all is said and done, the information provided on the medical record is the only existing verification of the content and extent of the service that was performed.
This case presents a challenge to the alert ED coder for a number of reasons. Initially, this patient presents as the victim of an automobile accident where the patient, as driver of the vehicle, sustained facial trauma. To the coder, this should be an immediate indication of the potential for additional injuries. These could be identified in order to qualify for an E/M level higher than is justified by just the surgical repair of the lacerations alone.
The level of E/M service is scored by identifying the components of the history, physical exam and medical decision-making documented by the physician. The components of the E/M are then compared to the types of laceration repair performed to determine what components of the E/M are considered part of the surgical package.
Scoring the History of Present Illness (HPI)
The physician in this case has provided clear information relating to three elements of the HPI: location (face, mouth, lips); context (unrestrained driver, motor vehicle accident [MVA]); and duration (prior to arrival).
Level of HPI: Brief
Scoring the Review of Systems (ROS)
Review [...]
