Case Study:
Patient with Multiple Orthopedic Injuries Evaluated and Treated by the ED Physician
Published on Thu Jul 01, 1999
by Caral Edelberg,CPC
Consulting Editor
Coders are frequently challenged to code for orthopedic procedures performed in the ED by the emergency physician. Depending on the extent of the injury, the experience of the emergency physician, and the sophistication of available technology, the physician may either treat the patient in the department, call in an orthopedist to treat the patient, or stabilize the patient and refer to an orthpedic specialist outside the ED for timely follow-up. The codes applied will vary greatly depending on which situation occurs.
Note: For more information on reporting orthopedic codes in the ED, see the article Use Orthopedic Codes Plus Modifier -54 to Get Paid for ED Fracture Care, page 3 of ED Coding Alert, December 1998.
This months case illustrates the importance of understanding the clinical limits of the emergency physicians involvement in treating orthopedic injuries, using an example of a patient who presents in the department after a fall down a flight of stairs (see sample patient chart on page 53).
Choosing a Version of E/M Documentation Guidelines
With the evaluation and management documentation guidelines in a state of fluxphysicians may use either the 1995 or the 1997 version of the CPT manualassigning a level to the physical exam involving two or more body areas or organ systems can be very confusing. Most physicians and coders agree that the 1995 version is the least burdensome. However, the introduction of the proposed bulleted format in the 1997 version caused confusion about what auditors consider acceptable documentation.
The 1997 set of guidelines differentiates body areas (e.g., head, neck, abdomen, genital/groin/buttocks, extremities, and back) from organ systems (e.g., constitutional, eyes, ENMT, respiratory, CV, GI, GU, musculoskeletal, hematologic/ immunologic/lymphatic).
For a 99285 (comprehensive examination) E/M level under the 1995 guidelines, HCFA specifically requires examination of organ systems (rather than body areas) and also states that a comprehensive exam is a complete exam of a systemnot (continued on next page) just a brief statement about that system.
There is no clarification within the 1995 guidelines that defines the difference between: 1) a body area and an organ system; or 2) what constitutes a comprehensive examination.
In this case, we have used the 1995 documentation guideline requirements to assign the level of physical exam, but also have mentioned which documentation provided by the physician also might be used to determine the content of the exam or differentiate an organ system from a body area using the 1997 criteria.
Scoring the History and Physical
The patient sustains multiple injuries in a fall and is transported to the ED via ambulance. Evaluating the physician documentation using the 1995 documentation guidelines, we assign levels to the history of present illness (HPI), [...]
